Could Patients’ Expectations Impact Clinical Response to DMARDs in Rheumatoid Arthritis?

A study observed a correlation between patients’ expectations toward newly induced disease-modifying antirheumatic drug (DMARD) therapies and clinical response among patients with rheumatoid arthritis (RA).

“The psychosocial dimensions of RA have received considerable attention in the past years. It is generally accepted that the psychosocial state impacts parameters such as disease activity and health-related quality of life (HrQoL) at baseline, but also longitudinally,” the study authors explained. “However, the association of initial illness perception on outcomes such as HrQoL and disease activity has not yet been investigated.”

The study comprised 100 patients with RA and an upcoming change in DMARD treatment due to non-response or adverse effects. The Beliefs About Medicines Questionnaire (BMQ), the Short Form 36, and self-designed questions about expectations before treatment initiation (T0) were all used to assess patients’ treatment beliefs and expectations, as well as HrQoL. Disease Activity Score 28 (DAS28)-C-reactive protein (CRP) was calculated at T0 and after four months (T4). Regression analyses after multiple imputation were implemented to characterize the relationship between patients’ beliefs and expectations and changes in DAS28-CRP (T0 to T4, ΔDAS28-CRP).

Data analysis comprised 99 patients, of whom 74 were female. The median age was 62 years (interquartile range, 53.5-70 years). Of the 99 patients, 84 patients completed all questionnaires; 64 of these patients were female. Fifty-three patients were started on a biological DMARD, and 46 were started on a conventional synthetic DMARD. There were no differences between patients started on biological versus conventional synthetic DMARDs. Nearly all patients had a history of failed DMARDs. Most patients had previously received methotrexate (62.6%), while 31.3% had received another conventional synthetic DMARD, and 5.1% treated with a biological DMARD, either alone or in combination with a conventional synthetic DMARD. There was one case of newly diagnosed RA.

Of 99 patients included, 84 completed the questionnaires. Overall, expectations per the questionnaires and CRP value at T0 accounted for 36% of all variability in treatment response (ΔDAS28-CRP).

“Among these,” the researchers noted, “the expected improvement rate, with 10.5%, as well as the CRP-value at T0, with 10.6%, had the greatest positive effect whereas the fear of adverse effects, with 11.4%, and the BMQ.concern scale, with 9.0%, had the greatest negative impact on ΔDAS28.”

A limitation of the study is the fact that it relied on self-reported, unverifiable data from the questionnaires. Patients also enrolled voluntarily and were not randomized.

The study was published in Therapeutic Advances in Musculoskeletal Disease.

“The integration of patients’ preferences and their expectations in treatment decisions could significantly increase clinical outcome. Hence, a more detailed analysis of prevailing expectations and factors that influence these expectations could identify valuable leverage points for non-pharmaceutical options to improve outcome,” the study authors wrote in their conclusion.