Background/Purpose: In rheumatoid arthritis (RA), patients’ and physicians’ perceptions of disease can differ and patients who are satisfied with their health do not tend to agree with escalation of drug therapy, even if disease activity is not low. It is hypothesized that patient acceptable symptom state, as well as perceived and expected change, influence patients’ willingness to alter therapy, in addition to disease activity state.

Objective: To investigate the influence of patient perceptions and disease activity on escalation of drug therapy in RA patients.

Methods: Consecutive RA patients attending the outpatient rheumatology clinic received standard clinical assessment including the DAS28 and medication changes. In addition, patients were asked 4 items regarding: perceived health state transition, satisfaction with their health state, willingness to change therapy and expected health state transition until the next visit. To investigate explanatory factors, logistic models predicting actual escalation of medication in daily practice and predicting patients’ self-reported willingness to escalate therapy were fitted by means of forward selection. Predictors for the models were: sex, age, rheumatoid factor, disease duration, DAS28 response since last visit, attained DAS28 level and the above mentioned patient perception items. Escalation of DMARD or biologic medication was defined as an increase in frequency and/or dose of medication, or starting a new one, between the current and next visit.

Results: In total 422 RA patients; 63.3% female, 67.1% rheumatoid factor positive were included in the analysis. Mean (SD) DAS28 at visit, age and disease duration in years were: 3.09(1.24), 58.6(12.95), 9.72(9.25), respectively. In total 185 (43.8%) patients had a DAS28>3.2, of whom 96 (59.1%) were satisfied with their health status if this would not change until the next visit, and a majority of patients 132 (71.4%) did not want to change their medication. Table 1 shows the final model for therapy escalation with a clear independent relationship of patient reported willingness to escalate therapy. Table 2 shows the model with willingness to escalate therapy as the outcome. All patient perception measures exhibited significant independent associations, of which patient satisfaction was strongest. Figure 1 shows a model of medication escalation in daily practice.

Conclusion: Patients’ willingness to escalate therapy is strongly associated with actual escalation of therapy in daily practice, independent of clinical parameters. In turn, patients’ willingness to escalate therapy is primarily associated with patients’ satisfaction with their health state, perceived change and expected change. Treat to target interventions should address patients’ perceptions of their disease, and the related health goals patients aim to achieve, next to the level of disease activity attained.