Background/Purpose: Little is known about the patient perspective related to DMARD choice in RA. Our objective was to assess how patients decide whether to add traditional oral DMARDs or injectable biologic DMARDs to methotrexate for the treatment of active RA.

Methods: We conducted 10 nominal groups in patients with RA from rheumatology clinics at two tertiary care centers at Birmingham (n=6; 21 patients) and New York City (n=4; 26 patients).  Patients provided responses to the question “What sort of things are important to you when you make a decision between adding pills versus injectable medications to treat rheumatoid arthritis when methotrexate fails to control RA disease activity?” Patients nominated, discussed and voted for the responses.

Results: Forty-seven patients participated in 10 nominal groups, who were predominantly female (85%), 70% white, with a mean (standard deviation) age of 64.5 years and 58% with >10 year RA duration. Present/past DMARDs included methotrexate in 91% and biologics and/or Jak-inhibitors in 68% of participants. The mean MD-HAQ score was 2 on a 0-10 scale and the mean RAPID-3 score on a 0-30 scale was 9.1. The main responses ranked by patients were as follows.

Efficacy/mode of action was among the voted domains in 10/10 nominal groups and got 28% of the votes (78/282 votes; Figure 1).  Side effects/fear of side effects was among the voted domains in 9/10 nominal groups and got 30% of the votes (84/282 votes).  Cost was among the voted domains in 9/10 nominal groups and got 19% of the votes (54/282 votes). Out of pocket costs, including co-payments and patient responsibility for the drug cost was the most important aspect of the medication cost that impacted the choice.  Convenience/frequency of use was among the voted domains in 9/10 nominal groups and got 10% of the votes (27/282 votes).  Doctor’s opinion was among the voted domains in 4/10 nominal groups and got 7% of the votes (20/282 votes). Patients greatly valued their rheumatologist’s opinion, which was either a strong factor or a deciding factor for them. Other drugs/comorbidity/other patient’s experience/effects on other people was among the voted domains in 3/10 nominal groups and got 1% of the votes (3/282 votes). Many patients worried about drug-drug interactions and contra-indications in the presence of other systemic conditions. Fear of Needles was among the voted domains in 1/10 nominal groups and got 3% of the votes (8/282 votes). People expressed “Fear of injections” “Anxiety about self-injecting”, and “Nauseating concept if you are not a medical person”.  The newness of the medication was among the voted domains in 1/10 nominal groups and got 3% of the votes (8/282 votes).

Conclusion: Our qualitative study identified the patient perspective of DMARD choice between oral versus injectable drugs once methotrexate fails to control disease activity. This knowledge can help in informative shared decision-making in regular clinical care.

Figures_RA_meds_NGT_abstract

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pop-a-pill-or-give-myself-a-shot-patient-perspectives-of-disease-modifying-anti-rheumatic-drug-dmard-choice-for-rheumatoid-arthritis-ra/