The Pharmaceutical Journal
Vol 273 No 7322 p590
23 October 2004

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Adverse effects have most influence on choice of rheumatic drug for older people

Many older patients with rheumatoid arthritis would prefer to be treated with a drug that has an unknown long-term safety profile but fewer immediate adverse effects than a more established drug with a greater number of adverse effects, even if these effects are reversible.

This is a finding of researchers who used an interactive computer program to determine which disease-modifying anti-rheumatic drug would best suit each of 120 patients.

They analysed patient trade-offs between different drug characteristics such as side effects, effectiveness and cost. Risk-benefit scenarios were simulated for methotrexate, gold, leflunomide (Arava) and etanercept (Enbrel), using lay terminology. How highly each patient valued each characteristic was then determined.

For example, patients rated decreasing the risk of nausea from 10 per cent to nil as important as changing the route of administration from twice weekly subcutaneous injections to a daily oral drug. Patients valued eliminating the risk of hepatotoxicity about 2.5 times more than improving the chance of benefiting from the drug by 25 per cent.

Overall, etanercept was the drug found to best fit most patient priorities. When the maximum benefits reported in the literature were assumed, etanercept was the derived preferred treatment option for 95 per cent of respondents. When all four treatment options were described as being equally effective, 88 per cent of patients were still predicted to prefer etanercept. The authors say that this can be explained by older patients’ risk aversion for drug toxicity.

In general, the elimination of adverse effects was valued more than the maximum improvement of specific benefits. For example, patients thought that improving the chance of benefit by 30 per cent was less important than eliminating the risk of common reversible adverse effects, such as diarrhoea or nausea, as well as rare but more serious adverse effects, such as hepatotoxicity, pneumonitis or a theoretical risk of cancer.

The authors say that although the results of this study are not meant to be prescriptive, they highlight the importance of incorporating patient values into treatment decisions involving disease-modifying anti-rheumatic drugs (Annals of Rheumatic Diseases 2004; 63:1372).