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Type: Journal article
Title: Characterising deviation from treat-to-target strategies for early rheumatoid arthritis: the first three years
Author: Wabe, N.
Sorich, M.
Wechalekar, M.
Cleland, L.
McWilliams, L.
Lee, A.
Spargo, L.
Metcalf, R.
Hall, C.
Proudman, S.
Wiese, M.
Citation: Arthritis Research and Therapy, 2015; 17(1):48-1-48-14
Publisher: BioMed Central
Issue Date: 2015
ISSN: 1478-6354
Statement of
Nasir Wabe, Michael J Sorich, Mihir D Wechalekar, Leslie G Cleland, Leah McWilliams, Anita Lee, Llewellyn Spargo, Robert G Metcalf, Cindy Hall, Susanna M Proudman, and Michael D Wiese
Abstract: INTRODUCTION: Treat-to-target (T2T) strategies using a protocol of pre-defined adjustments of disease-modifying anti-rheumatic drugs (DMARDs) according to disease activity improve outcomes for patients with rheumatoid arthritis (RA). However, successful implementation may be limited by deviations from the protocol. The aim of this study was to determine the prevalence of protocol deviation, explore the reasons and identify subsets of patients in whom treatment protocols are more difficult to follow. METHODS: In this retrospective cohort study, treatment-naïve patients with RA of less than one year's duration, attending a dedicated early arthritis clinic between 2001 and 2013, were followed for three years from initiation of combination therapy with conventional DMARDs which was subsequently modified according to a T2T protocol. At each clinic visit, whether deviation from the protocol occurred, the type of deviation and the reasons for deviation were assessed. The relationship between protocol deviations and baseline variables was determined using linear regression analysis. RESULTS: In total, 198 patients contributed 3,654 clinic visits. The prevalence of protocol deviations was 24.5% and deviation in at least at one clinic visit was experienced by 90.4% of patients. The median time to first deviation was 30 weeks. Continuing existing treatment rather than intensifying therapy was the most common type of deviation (59.9%). Patient and physician related factors were the most common reasons for deviation, each accounting for 24.7% of deviations, followed by toxicities (23.3%) and comorbidities (20.0%). The prevalence of protocol deviations was lower among patients who achieved remission after three years (13.1%; 162 deviations out of 1,228 visits) compared with those who were not in remission (30.9%; 523/1692) (P<0.0001). On multivariate analysis, only body mass index (P=0.003) and helplessness score (P=0.04) were independent predictors of protocol deviations although the predictive power of the model was not strong (R2=0.17). CONCLUSIONS: Deviation from a T2T protocol occurred in one quarter of visits, indicating that applying the T2T approach is feasible in clinical practice. Failure to escalate dose when indicated was commonly encountered, and just under half of the observed deviations were related to either toxicities or comorbidities and were therefore justifiable on clinical grounds.
Keywords: Humans; Arthritis, Rheumatoid; Antirheumatic Agents; Treatment Outcome; Remission Induction; Severity of Illness Index; Retrospective Studies; Follow-Up Studies; Time Factors; Adult; Aged; Middle Aged; Female; Male; Practice Guidelines as Topic
Rights: © 2015 Wabe et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
RMID: 0030026502
DOI: 10.1186/s13075-015-0562-0
Appears in Collections:Medicine publications

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