HOW DO FRENCH RHEUMATOLOGISTS TREAT EARLY RHEUMATOID-ARTHRITIS

Although factors that appear to predict long-term outcomes of rheumato id arthritis have been identified, there is no consensus about the tre atment early in the disease. To determine how French office- and hospi tal-based rheumatologists treat early rheumatoid arthritis, we created three clinical vignettes corresponding to different levels of severit y of early rheumatoid arthritis (less than six months' disease duratio n). Cases 1 and 2 were relatively young patients (35 and 50 years), an d Case 1 had numerous poor prognosis factors. Case 3 was 80 years of a ge. Rheumatologists were asked to indicate which medications they woul d use at presentation and after one year of a favorable or unfavorable course. The study was conducted by questionnaire (response rate, 58%) . Of the 185 rheumatologists who completed the questionnaire, 81% were male and 19% female; mean age was 42+/-8 years. In Cases 1 and 2, non steroidal antiinflammatory drugs were given by 99% of respondents; sec ond-line drugs were prescribed at presentation by 93% of respondents i n Case 1 and 86% in Case 2, and methotrexate was more likely to be use d in the presence of poor prognosis factors (23% in case 1 and 7% in C ase 2). In the event of an unfavorable course after one year; a larger proportion of rheumatologists prescribed glucocorticoid therapy (65% in Case 1 and 20% in Case 2), and there was a shift from <<conventiona l>> to <<modern>> second-line drugs, with more widespread use of metho trexate (65% in case 1 and 18% in case 2). In the 80-year-old patient, glucocorticoid therapy was used more often than nonsteroidal antiinfl ammatory drugs and second-line drugs (gold salts, hydroxychloroquine, sulfasalazine) were prescribed by 40% of rheumatologists at presentati on and by 67% after one year of an unfavorable course; in the latter s ituation, methotrexate was selected in 24% of cases. In contrast to co nventional recommendations, many French office- or hospital-based rheu matologists use second-line drugs very early and base their choice of medications on the estimated risk of severe disease and on the age of the patient.