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Preventive Treatments for Rheumatoid Arthritis: Issues Regarding Patient Preferences

  • Health Economics and Quality of Life (M Harrison, Section Editor)
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Abstract

The detection of biomarkers in the preclinical phase of rheumatoid arthritis (RA) and recent therapeutic advances suggest that it may be possible to identify and treat persons at high risk and to prevent the development of RA. Several trials are ongoing to test the efficacy of a therapeutic intervention in primary prevention. This paper reviews potential populations that might be considered for preventative medication. Further, we review the medications that are being explored to treat individuals considered at high risk of developing RA. Finally, in a group of asymptomatic individuals at high risk of developing RA, we assessed which factors mattered most when considering a preventive therapeutic intervention and what type of preventive treatment would be most acceptable to them. Understanding subjects’ perceptions of risks and benefits and willingness to undergo preventive therapy will be important in designing and implementing screening and preventive strategies.

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Acknowledgments

We thank Mehdi Najafzadeh for his assistance with the analysis of the data.

Author information

Authors and Affiliations

  1. Division of Rheumatology, University Hospitals of Geneva (HUG), 26, Av. Beau-Séjour, CH-1211, Geneva 14, Switzerland

    Axel Finckh

  2. Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland

    Monica Escher

  3. Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA, USA

    Matthew H. Liang

  4. Section of Rheumatology, VA Boston Healthcare System, Boston, MA, USA

    Matthew H. Liang

  5. School of Population and Public Health, University of British Columbia, Vancouver, Canada

    Nick Bansback

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  1. Axel Finckh
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  2. Monica Escher
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Corresponding author

Correspondence to Axel Finckh.

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Conflict of Interest

AF, ME, MHL, and NB declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

All reported experiments with human subjects performed by the authors were in compliance with all applicable ethical standards (including the Helsinki Declaration and its amendments, institutional research committee standards, and national guidelines).

Funding

This work was supported by the Swiss National Science Foundation [3200B0_120639/1].

Additional information

This article is part of the Topical Collection on Health Economics and Quality of Life

Appendices

Appendix: Background information and instructions to this binary choice questionnaire

Explanation about the study

In the following sections, we will present various preventive treatment options. Each treatment option is associated with 4 characteristics. These attributes are the following:

  • Reduction in the risk of developing rheumatoid arthritis (RA)

  • Risk of having a major side effect related to the preventive treatment

  • Risk of having a minor side effect related to the preventive treatment

  • How the treatment is administered

For each treatment option, we ask you to choose the attribute that you find best and the feature you find worst.

Following this step, we will present you a hypothetical risk of developing RA and ask you whether, with such a risk, you would take the treatment option presented previously or not. Note that the proposed treatment would cost you nothing.

Attributes of the treatment options

Each treatment option has a unique combination of attributes. We will briefly detail these attributes.

  1. 1.

    Reduction in the risk of developing rheumatoid arthritis:

    This refers to the effectiveness of treatment. By taking a drug, we hope to reduce the risk of developing rheumatoid arthritis (RA). However, currently, we do not yet know precisely the effectiveness of the preventive treatment. The treatment could only delay the onset of the disease or it could completely prevent its occurrence. This is called risk reduction in developing the disease.

    Example:

    Suppose your initial risk of developing the disease was 50 % (or 1 chance in 2). If a preventive treatment decreased the risk of developing RA by 75 % (or a 75 % risk reduction in developing RA), then your risk of developing the disease would be reduced to 12.5 % (or 1 chance in 8 ).

    The options offered in the questionnaire are

    • 0 % (taking therapy will only delay the onset of RA).

    • 20 % (or 1 in 5 will not develop RA because of the treatment).

    • 40 % (or 2 out of 5 people will not develop RA because of treatment).

    • 80 % (or 4 out of 5 people will not develop RA because of treatment).

  2. 2.

    Risk of a major side effect

    Here, we refer to an adverse event due to the treatment that would result in hospitalization or require specific treatment. For example, a major side effect could be an infection with an unusual microorganism, requiring treatment with antibiotics. These types of infection usually heal without permanent damage. However, there remains the possibility such an infection may be life-threatening.

    In order to be consistent with the wording of the other questions, we present the risk of major side effects as “the chance not to develop a major side effect.” The options offered in the questionnaire are

    • >99 % chances not to develop a major side effect (= less than one in 100 persons will experience a major side effect).

    • 95 % chances not to develop a major side effect (=5 out 100 persons will experience a major side effect).

    • 90 % chances not to develop a major side effect (= 10 out 100 persons will experience a major side effect).

    • 80 % chances not to develop a major side effect (= 20 out 100 persons will experience a major side effect).

  3. 3.

    Probability of a minor side effect

    Minor side effects normally require no treatment. Examples of these side effects may include headaches, transient flu-like symptoms, or a localized skin reaction.

    In order to be consistent with the wording of the other questions, we present the risk of major side effects as “the chance not to develop a minor side effect”. The options offered in the questionnaire are

    • 95 % chances not to develop a minor side effect (= 5 out 100 persons will experience a minor side effect).

    • 90 % chances not to develop a minor side effect (= 10 out 100 persons will suffer a major side effect).

    • 80 % chances not to develop a minor side effect (= 20 out 100 persons will suffer a major side effect).

    • 60 % chances not to develop a minor side effect (= 40 out 100 persons will suffer a major side effect).

  4. 4.

    How the treatment is administered

    The proposed medications are antirheumatic treatments commonly used for patients with RA (these are not experimental drugs). As preventive treatments, we believe they should be taken for at least a year.

    There are different ways these drugs may be administered:

    • Tablets to be taken daily by mouth (oral).

    • A subcutaneous injection (under the skin prick), self-administered every two weeks.

    • A monthly intravenous infusion (short-term infusion in the hospital: ½ - 1 hour).

    • 1 or 2 single intravenous infusion (longer infusion in the hospital: 4-5 hours).

Reduction in the risk of developing RA

We first present you a hypothetical risk of developing RA. These different levels of risk are evaluated based on test results, similar to those you have just performed.

The level of risk that you are presented are

  • 1 % (=1 in 100 people will develop the disease)

  • 20 % (=1 in 5 will develop the disease)

  • 40 % (=2 out of 5 people will develop the disease)

  • 80 % (=4 out of 5 people will develop the disease)

Given such a risk, we will then ask you whether you would take the treatment option presented previously or not.

_______

On the following pages, nine different treatment options will be presented. You will then be asked to choose the best and worst feature for each option, and you may decide whether or not take the proposed treatment.

We are aware that issues may seem repetitive, but we are very interested to see how you respond to each of them.

Please press “Next” to see an example question.

Figure 1 Sample task of the of binary choice questionnaire

Question 1

Below is an example of a potential treatment that you could be offered to reduce your risk of developing rheumatoid arthritis. Please pick the feature that you consider the best among the characteristics of this preventive treatment. Also please choose the worst feature of the proposed preventive treatment.

We remind you that the proposed treatment would cost you nothing (fully supported) and that the therapy duration is at least one year (with the exception of the intravenous infusion therapy which has a very long duration).

Which of the attributes below would you consider the best and the worst attribute of the proposed preventive treatment?

Treatment

Best

Worst

20 % risk reduction in risk of developing RA:

✓

 

80 % risk of not developing a mild side effect

  

95 % risk of not developing a mild side effect

  

Oral daily tablet for one year

 

✓

Now, assuming that the analyses of your blood tests predict a risk of 1 % (1 in 100 chance) of developing rheumatoid arthritis, would you take the treatment described above?

YES / NO

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Finckh, A., Escher, M., Liang, M.H. et al. Preventive Treatments for Rheumatoid Arthritis: Issues Regarding Patient Preferences. Curr Rheumatol Rep 18, 51 (2016). https://doi.org/10.1007/s11926-016-0598-4

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