Rethinking the discordance between guidelines and practice in rheumatoid arthritis treatment

Inam, Shafqat; Lipworth, Wendy L; Kerridge, Ian H; Day, Richard O

doi:10.5694/mja11.10068

A failure of practice, or a failure of evidence?

Drug treatment of rheumatoid arthritis (RA) has evolved significantly in recent decades, owing to increasing evidence supporting early intervention with disease-modifying therapies and the advent of novel biological therapies that specifically target the immunological and cellular mediators of disease.

1 Department of Medicine, Royal Prince Alfred Hospital, Sydney, NSW.
2 Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW.
3 Centre for Values, Ethics and Law in Medicine, University of Sydney, Sydney, NSW.
4 University of New South Wales, Sydney, NSW.
5 Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, NSW.

Correspondence: shafqat.inam@gmail.com

Competing interests:

No relevant disclosures.

1. Donahue KE, Gartlehner G, Jonas DE, et al. Systematic review: comparative effectiveness and harms of disease-modifying medications for rheumatoid arthritis. Ann Intern Med 2008; 148: 124-134.
2. Gartlehner G, Hansen RA, Jonas BL, et al. The comparative efficacy and safety of biologics for the treatment of rheumatoid arthritis: a systematic review and metaanalysis. J Rheumatol 2006; 33: 2398-2408.
3. Royal Australian College of General Practitioners. Clinical guideline for the diagnosis and management of early rheumatoid arthritis. Melbourne: RACGP, 2009.
4. Kay J, Westhovens R. Methotrexate: the gold standard without standardisation. Ann Rheum Dis 2009; 68: 1081-1082.
5. Siegel J. Comparative effectiveness of treatments for rheumatoid arthritis. Ann Intern Med 2008; 148: 162-163.
6. Zink A, Askling J, Dixon WG, et al. European biologicals registers: methodology, selected results and perspectives. Ann Rheum Dis 2009; 68: 1240-1246.
7. Kalden JR, Antoni C, Alvaro-Gracia JM, et al. Use of combination of leflunomide with biological agents in treatment of rheumatoid arthritis. J Rheumatol 2005; 32: 1620-1631.
8. Benhamou M, Rincheval N, Roy C, et al. The gap between practice and guidelines in the choice of first-line disease modifying antirheumatic drug in early rheumatoid arthritis: results from the ESPOIR cohort. J Rheumatol 2009; 36: 934-942.
9. Lacaille D, Anis AH, Guh DP, Esdaile JM. Gaps in care for rheumatoid arthritis: a population study. Arthritis Rheum 2005; 53: 241-248.
10. Grol R. Has guideline development gone astray? Yes. BMJ 2010; 340: c306.
11. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458-1465.
12. Boers M. Cost-effectiveness of biologics as first-line treatment of rheumatoid arthritis: case closed? Ann Intern Med 2009; 151: 668-669.
13. Australian Government Department of Health and Ageing. The national strategy for quality use of medicines. Plain English edition. Canberra: Commonwealth of Australia, 2002. http://www.health.gov.au/internet/main/publishing.nsf/content/nmp-pdf-natstrateng-cnt.htm

Online responses are no longer available. Please refer to our instructions for authors page for more information.