Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology
Identifieur interne : 001A34 ( Istex/Corpus ); précédent : 001A33; suivant : 001A35Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology
Auteurs : X. Le Loët ; J M Berthelot ; A. Cantagrel ; B. Combe ; M. De Bandt ; B. Fautrel ; R M Flipo ; F. Lioté ; J F Maillefert ; O. Meyer ; A. Saraux ; D. Wendling ; F. GuilleminSource :
- Annals of the Rheumatic Diseases [ 0003-4967 ] ; 2006-01.
English descriptors
- KwdEn :
- Teeft :
- American college, Antirheumatic, Antirheumatic drug, Antirheumatic drugs, Arthritis, Arthritis rheum, Bichat paris university hospital, Biological agents, Citrulline peptide antibodies, Clinical experience, Clinical situation, Clinical situations, Correspondence factor analysis, Decision tree, Delphi method, Disease activity, Dmard, Dmard characteristics, Dmard choice, Dmards, Early disease, Erythrocyte sedimentation rate, Expert panel, Final choice, First disease, First dmard, French society, Guideline, High disease activity, High level, Initial presence, Joint damage, Joint disease activity score, Leflunomide, Literature review, Medical history, Methotrexate, Nancy university hospital, Patient characteristics, Physician characteristics, Polyarthrite rhumatoide, Principal items, Prognostic factors, Radiographic damage, Ranking choices, Reactive protein, Recent onset, Recent reviews, Rheum, Rheumatoid, Rheumatoid arthritis, Rheumatoid arthritis activity, Rheumatoid factor, Rheumatoid factor positivity, Rheumatoid factor status, Rheumatology, Scenario, Second choice, Stpr experts, Strategies therapeutiques, Structural damage, Structural involvement, Swollen joints, Treatment options, Treatment strategy.
Abstract
Objective: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration. Methods: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. Results: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. Conclusions: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.
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DOI: 10.1136/ard.2005.035436
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ISTEX:FCE32DE33991918A6405865080D3DF7C30A1993ALe document en format XML
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Cantagrel</name><affiliation><mods:affiliation>Department of Rheumatology, Toulouse University Hospital, Toulouse, France</mods:affiliation></affiliation></author><author><name sortKey="Combe, B" sort="Combe, B" uniqKey="Combe B" first="B" last="Combe">B. Combe</name><affiliation><mods:affiliation>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</mods:affiliation></affiliation></author><author><name sortKey="De Bandt, M" sort="De Bandt, M" uniqKey="De Bandt M" first="M" last="De Bandt">M. De Bandt</name><affiliation><mods:affiliation>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</mods:affiliation></affiliation></author><author><name sortKey="Fautrel, B" sort="Fautrel, B" uniqKey="Fautrel B" first="B" last="Fautrel">B. Fautrel</name><affiliation><mods:affiliation>Department of Rheumatology, La Pitié Paris University Hospital, Paris</mods:affiliation></affiliation></author><author><name sortKey="Flipo, R M" sort="Flipo, R M" uniqKey="Flipo R" first="R M" last="Flipo">R M Flipo</name><affiliation><mods:affiliation>Department of Rheumatology, Lille University Hospital, Lille, France</mods:affiliation></affiliation></author><author><name sortKey="Liote, F" sort="Liote, F" uniqKey="Liote F" first="F" last="Lioté">F. 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Saraux</name><affiliation><mods:affiliation>Department of Rheumatology, Brest University Hospital, Brest, France</mods:affiliation></affiliation></author><author><name sortKey="Wendling, D" sort="Wendling, D" uniqKey="Wendling D" first="D" last="Wendling">D. Wendling</name><affiliation><mods:affiliation>Department of Rheumatology, Besançon University Hospital, Besançon, France</mods:affiliation></affiliation></author><author><name sortKey="Guillemin, F" sort="Guillemin, F" uniqKey="Guillemin F" first="F" last="Guillemin">F. Guillemin</name><affiliation><mods:affiliation>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:FCE32DE33991918A6405865080D3DF7C30A1993A</idno><date when="2006" year="2006">2006</date><idno type="doi">10.1136/ard.2005.035436</idno><idno type="url">https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/fulltext.pdf</idno><idno type="wicri:Area/Istex/Corpus">001A34</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">001A34</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology</title><author><name sortKey="Le Loet, X" sort="Le Loet, X" uniqKey="Le Loet X" first="X" last="Le Loët">X. Le Loët</name><affiliation><mods:affiliation>Department of Rheumatology, Rouen University Hospital, Rouen, France</mods:affiliation></affiliation></author><author><name sortKey="Berthelot, J M" sort="Berthelot, J M" uniqKey="Berthelot J" first="J M" last="Berthelot">J M Berthelot</name><affiliation><mods:affiliation>Department of Rheumatology, Nantes University Hospital, Nantes, France</mods:affiliation></affiliation></author><author><name sortKey="Cantagrel, A" sort="Cantagrel, A" uniqKey="Cantagrel A" first="A" last="Cantagrel">A. Cantagrel</name><affiliation><mods:affiliation>Department of Rheumatology, Toulouse University Hospital, Toulouse, France</mods:affiliation></affiliation></author><author><name sortKey="Combe, B" sort="Combe, B" uniqKey="Combe B" first="B" last="Combe">B. Combe</name><affiliation><mods:affiliation>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</mods:affiliation></affiliation></author><author><name sortKey="De Bandt, M" sort="De Bandt, M" uniqKey="De Bandt M" first="M" last="De Bandt">M. De Bandt</name><affiliation><mods:affiliation>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</mods:affiliation></affiliation></author><author><name sortKey="Fautrel, B" sort="Fautrel, B" uniqKey="Fautrel B" first="B" last="Fautrel">B. Fautrel</name><affiliation><mods:affiliation>Department of Rheumatology, La Pitié Paris University Hospital, Paris</mods:affiliation></affiliation></author><author><name sortKey="Flipo, R M" sort="Flipo, R M" uniqKey="Flipo R" first="R M" last="Flipo">R M Flipo</name><affiliation><mods:affiliation>Department of Rheumatology, Lille University Hospital, Lille, France</mods:affiliation></affiliation></author><author><name sortKey="Liote, F" sort="Liote, F" uniqKey="Liote F" first="F" last="Lioté">F. Lioté</name><affiliation><mods:affiliation>Department of Rheumatology, Lariboisière Paris University Hospital, Paris</mods:affiliation></affiliation></author><author><name sortKey="Maillefert, J F" sort="Maillefert, J F" uniqKey="Maillefert J" first="J F" last="Maillefert">J F Maillefert</name><affiliation><mods:affiliation>Department of Rheumatology, Dijon University Hospital, Dijon, France</mods:affiliation></affiliation></author><author><name sortKey="Meyer, O" sort="Meyer, O" uniqKey="Meyer O" first="O" last="Meyer">O. Meyer</name><affiliation><mods:affiliation>Department of Rheumatology, Bichat Paris University Hospital</mods:affiliation></affiliation></author><author><name sortKey="Saraux, A" sort="Saraux, A" uniqKey="Saraux A" first="A" last="Saraux">A. Saraux</name><affiliation><mods:affiliation>Department of Rheumatology, Brest University Hospital, Brest, France</mods:affiliation></affiliation></author><author><name sortKey="Wendling, D" sort="Wendling, D" uniqKey="Wendling D" first="D" last="Wendling">D. Wendling</name><affiliation><mods:affiliation>Department of Rheumatology, Besançon University Hospital, Besançon, France</mods:affiliation></affiliation></author><author><name sortKey="Guillemin, F" sort="Guillemin, F" uniqKey="Guillemin F" first="F" last="Guillemin">F. Guillemin</name><affiliation><mods:affiliation>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Annals of the Rheumatic Diseases</title><title level="j" type="abbrev">Ann Rheum Dis</title><idno type="ISSN">0003-4967</idno><idno type="eISSN">1468-2060</idno><imprint><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><date type="published" when="2006-01">2006-01</date><biblScope unit="volume">65</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="45">45</biblScope></imprint><idno type="ISSN">0003-4967</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0003-4967</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>DAS 28, 28 joint disease activity score</term><term>DMARD choice</term><term>DMARD, disease modifying antirheumatic drug</term><term>decision tree</term><term>early rheumatoid arthritis</term></keywords><keywords scheme="Teeft" xml:lang="en"><term>American college</term><term>Antirheumatic</term><term>Antirheumatic drug</term><term>Antirheumatic drugs</term><term>Arthritis</term><term>Arthritis rheum</term><term>Bichat paris university hospital</term><term>Biological agents</term><term>Citrulline peptide antibodies</term><term>Clinical experience</term><term>Clinical situation</term><term>Clinical situations</term><term>Correspondence factor analysis</term><term>Decision tree</term><term>Delphi method</term><term>Disease activity</term><term>Dmard</term><term>Dmard characteristics</term><term>Dmard choice</term><term>Dmards</term><term>Early disease</term><term>Erythrocyte sedimentation rate</term><term>Expert panel</term><term>Final choice</term><term>First disease</term><term>First dmard</term><term>French society</term><term>Guideline</term><term>High disease activity</term><term>High level</term><term>Initial presence</term><term>Joint damage</term><term>Joint disease activity score</term><term>Leflunomide</term><term>Literature review</term><term>Medical history</term><term>Methotrexate</term><term>Nancy university hospital</term><term>Patient characteristics</term><term>Physician characteristics</term><term>Polyarthrite rhumatoide</term><term>Principal items</term><term>Prognostic factors</term><term>Radiographic damage</term><term>Ranking choices</term><term>Reactive protein</term><term>Recent onset</term><term>Recent reviews</term><term>Rheum</term><term>Rheumatoid</term><term>Rheumatoid arthritis</term><term>Rheumatoid arthritis activity</term><term>Rheumatoid factor</term><term>Rheumatoid factor positivity</term><term>Rheumatoid factor status</term><term>Rheumatology</term><term>Scenario</term><term>Second choice</term><term>Stpr experts</term><term>Strategies therapeutiques</term><term>Structural damage</term><term>Structural involvement</term><term>Swollen joints</term><term>Treatment options</term><term>Treatment strategy</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Objective: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration. Methods: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. Results: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. Conclusions: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.</div></front></TEI><istex><corpusName>bmj</corpusName><keywords><teeft><json:string>rheumatoid</json:string><json:string>dmard</json:string><json:string>rheumatoid arthritis</json:string><json:string>structural damage</json:string><json:string>rheumatology</json:string><json:string>arthritis</json:string><json:string>antirheumatic</json:string><json:string>decision tree</json:string><json:string>dmards</json:string><json:string>methotrexate</json:string><json:string>guideline</json:string><json:string>first dmard</json:string><json:string>arthritis rheum</json:string><json:string>antirheumatic drug</json:string><json:string>rheum</json:string><json:string>leflunomide</json:string><json:string>disease activity</json:string><json:string>scenario</json:string><json:string>expert 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strategy</json:string><json:string>joint damage</json:string><json:string>polyarthrite rhumatoide</json:string><json:string>strategies therapeutiques</json:string></teeft></keywords><author><json:item><name>X Le Loët</name><affiliations><json:string>Department of Rheumatology, Rouen University Hospital, Rouen, France</json:string></affiliations></json:item><json:item><name>J M Berthelot</name><affiliations><json:string>Department of Rheumatology, Nantes University Hospital, Nantes, France</json:string></affiliations></json:item><json:item><name>A Cantagrel</name><affiliations><json:string>Department of Rheumatology, Toulouse University Hospital, Toulouse, France</json:string></affiliations></json:item><json:item><name>B Combe</name><affiliations><json:string>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</json:string></affiliations></json:item><json:item><name>M De Bandt</name><affiliations><json:string>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</json:string></affiliations></json:item><json:item><name>B Fautrel</name><affiliations><json:string>Department of Rheumatology, La Pitié Paris University Hospital, Paris</json:string></affiliations></json:item><json:item><name>R M Flipo</name><affiliations><json:string>Department of Rheumatology, Lille University Hospital, Lille, France</json:string></affiliations></json:item><json:item><name>F Lioté</name><affiliations><json:string>Department of Rheumatology, Lariboisière Paris University Hospital, Paris</json:string></affiliations></json:item><json:item><name>J F Maillefert</name><affiliations><json:string>Department of Rheumatology, Dijon University Hospital, Dijon, France</json:string></affiliations></json:item><json:item><name>O Meyer</name><affiliations><json:string>Department of Rheumatology, Bichat Paris University Hospital</json:string></affiliations></json:item><json:item><name>A Saraux</name><affiliations><json:string>Department of Rheumatology, Brest University Hospital, Brest, France</json:string></affiliations></json:item><json:item><name>D Wendling</name><affiliations><json:string>Department of Rheumatology, Besançon University Hospital, Besançon, France</json:string></affiliations></json:item><json:item><name>F Guillemin</name><affiliations><json:string>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>DAS 28, 28 joint disease activity score</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>DMARD, disease modifying antirheumatic drug</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>decision tree</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>early rheumatoid arthritis</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>DMARD choice</value></json:item></subject><arkIstex>ark:/67375/NVC-F4VXKQT6-1</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>other</json:string></originalGenre><abstract>Objective: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration. Methods: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. Results: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. Conclusions: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.</abstract><qualityIndicators><score>8.98</score><pdfWordCount>4160</pdfWordCount><pdfCharCount>27899</pdfCharCount><pdfVersion>1.3</pdfVersion><pdfPageCount>6</pdfPageCount><pdfPageSize>612 x 792 pts (letter)</pdfPageSize><refBibsNative>true</refBibsNative><abstractWordCount>235</abstractWordCount><abstractCharCount>1635</abstractCharCount><keywordCount>5</keywordCount></qualityIndicators><title>Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology</title><pmid><json:string>15994280</json:string></pmid><genre><json:string>other</json:string></genre><host><title>Annals of the Rheumatic Diseases</title><language><json:string>unknown</json:string></language><issn><json:string>0003-4967</json:string></issn><eissn><json:string>1468-2060</json:string></eissn><volume>65</volume><issue>1</issue><pages><first>45</first></pages><genre><json:string>journal</json:string></genre><subject><json:item><value>Immunology (including allergy)</value></json:item><json:item><value>Biological agents</value></json:item><json:item><value>Connective tissue disease</value></json:item><json:item><value>Degenerative joint disease</value></json:item><json:item><value>Drugs: musculoskeletal and joint diseases</value></json:item><json:item><value>Musculoskeletal syndromes</value></json:item><json:item><value>Rheumatoid arthritis</value></json:item></subject></host><namedEntities><unitex><date><json:string>2005-06-30</json:string><json:string>2004</json:string></date><geogName></geogName><orgName><json:string>Department of Public Health, Nancy University Hospital, Nancy, France APPENDIX The</json:string><json:string>Hospital, Paris R</json:string><json:string>Hospital, Besancon, France</json:string><json:string>Department of Rheumatology, Rouen University Hospital</json:string><json:string>Department of Rheumatology, Nantes University Hospital, Nantes, France A Cantagrel, Department of Rheumatology, Toulouse University Hospital, Toulouse, France B Combe, Federation of Rheumatology, Montpellier University Hospital, Montpellier, France M De Bandt, Department of Rheumatology, Bichat Paris University Hospital, Paris, France B Fautrel, Department of Rheumatology, La Pitie Paris University</json:string><json:string>Hospital, Paris J F Maillefert, Department of Rheumatology, Dijon University Hospital, Dijon, France O Meyer, Department of Rheumatology, Bichat Paris University Hospital A Saraux, Department of Rheumatology, Brest University Hospital, Brest, France</json:string><json:string>American College of Rheumatology</json:string><json:string>Department of Rheumatology, Lille University Hospital, Lille, France F Liote, Department of Rheumatology, Lariboisiere Paris University</json:string><json:string>Department of Rheumatology, Besancon University</json:string></orgName><orgName_funder></orgName_funder><orgName_provider></orgName_provider><persName><json:string>Xavier Le Loet</json:string><json:string>Janet Jacobson</json:string><json:string>Recent</json:string></persName><placeName><json:string>Delphi</json:string><json:string>Paris</json:string><json:string>Rouen</json:string><json:string>France</json:string></placeName><ref_url></ref_url><ref_bibl><json:string>Smolen et al</json:string><json:string>Shekelle et al.</json:string><json:string>February 2004</json:string><json:string>Wolfe et al</json:string><json:string>Shekelle et al</json:string><json:string>November 2003</json:string></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/NVC-F4VXKQT6-1</json:string></ark><categories><wos><json:string>1 - science</json:string><json:string>2 - rheumatology</json:string></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - clinical medicine</json:string><json:string>3 - arthritis & rheumatology</json:string></scienceMetrix><scopus><json:string>1 - Life Sciences</json:string><json:string>2 - Biochemistry, Genetics and Molecular Biology</json:string><json:string>3 - General Biochemistry, Genetics and Molecular Biology</json:string><json:string>1 - Life Sciences</json:string><json:string>2 - Immunology and Microbiology</json:string><json:string>3 - Immunology</json:string><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - Immunology and Allergy</json:string><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - Rheumatology</json:string></scopus><inist><json:string>1 - sciences appliquees, technologies et medecines</json:string><json:string>2 - sciences biologiques et medicales</json:string><json:string>3 - sciences medicales</json:string><json:string>4 - pathologie osteoarticulaire</json:string></inist></categories><publicationDate>2006</publicationDate><copyrightDate>2006</copyrightDate><doi><json:string>10.1136/ard.2005.035436</json:string></doi><id>FCE32DE33991918A6405865080D3DF7C30A1993A</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/fulltext.pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/bundle.zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/fulltext.tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher scheme="https://publisher-list.data.istex.fr">BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><availability><licence><p>Copyright 2006 by Annals of the Rheumatic Diseases</p></licence><p scheme="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-7M42M2QJ-2">bmj</p></availability><date>2005-06-30</date></publicationStmt><notesStmt><note type="other" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-7474895G-0">other</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note><note>Correspondence to:
Professor Xavier Le Loët
Service de Rhumatologie, CHU–Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France; xavier.le-loet@chu-rouen.fr</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology</title><author xml:id="author-0000"><persName><forename type="first">X</forename><surname>Le Loët</surname></persName><affiliation>Department of Rheumatology, Rouen University Hospital, Rouen, France</affiliation></author><author xml:id="author-0001"><persName><forename type="first">J M</forename><surname>Berthelot</surname></persName><affiliation>Department of Rheumatology, Nantes University Hospital, Nantes, France</affiliation></author><author xml:id="author-0002"><persName><forename type="first">A</forename><surname>Cantagrel</surname></persName><affiliation>Department of Rheumatology, Toulouse University Hospital, Toulouse, France</affiliation></author><author xml:id="author-0003"><persName><forename type="first">B</forename><surname>Combe</surname></persName><affiliation>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</affiliation></author><author xml:id="author-0004"><persName><forename type="first">M</forename><surname>De Bandt</surname></persName><affiliation>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</affiliation></author><author xml:id="author-0005"><persName><forename type="first">B</forename><surname>Fautrel</surname></persName><affiliation>Department of Rheumatology, La Pitié Paris University Hospital, Paris</affiliation></author><author xml:id="author-0006"><persName><forename type="first">R M</forename><surname>Flipo</surname></persName><affiliation>Department of Rheumatology, Lille University Hospital, Lille, France</affiliation></author><author xml:id="author-0007"><persName><forename type="first">F</forename><surname>Lioté</surname></persName><affiliation>Department of Rheumatology, Lariboisière Paris University Hospital, Paris</affiliation></author><author xml:id="author-0008"><persName><forename type="first">J F</forename><surname>Maillefert</surname></persName><affiliation>Department of Rheumatology, Dijon University Hospital, Dijon, France</affiliation></author><author xml:id="author-0009"><persName><forename type="first">O</forename><surname>Meyer</surname></persName><affiliation>Department of Rheumatology, Bichat Paris University Hospital</affiliation></author><author xml:id="author-0010"><persName><forename type="first">A</forename><surname>Saraux</surname></persName><affiliation>Department of Rheumatology, Brest University Hospital, Brest, France</affiliation></author><author xml:id="author-0011"><persName><forename type="first">D</forename><surname>Wendling</surname></persName><affiliation>Department of Rheumatology, Besançon University Hospital, Besançon, France</affiliation></author><author xml:id="author-0012"><persName><forename type="first">F</forename><surname>Guillemin</surname></persName><affiliation>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</affiliation></author><idno type="istex">FCE32DE33991918A6405865080D3DF7C30A1993A</idno><idno type="ark">ark:/67375/NVC-F4VXKQT6-1</idno><idno type="DOI">10.1136/ard.2005.035436</idno><idno type="href">annrheumdis-65-45.pdf</idno><idno type="PMID">15994280</idno><idno type="local">0650045</idno></analytic><monogr><title level="j">Annals of the Rheumatic Diseases</title><title level="j" type="abbrev">Ann Rheum Dis</title><idno type="pISSN">0003-4967</idno><idno type="eISSN">1468-2060</idno><idno type="PublisherID-hwp">annrheumdis</idno><idno type="PublisherID-nlm-ta">Ann Rheum Dis</idno><imprint><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><date type="published" when="2006-01"></date><biblScope unit="volume">65</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="45">45</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2005-06-30</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Objective: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration. Methods: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. Results: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. Conclusions: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.</p></abstract><textClass xml:lang="en"><keywords scheme="keyword"><list><head>ABR</head><item><term>DAS 28, 28 joint disease activity score</term></item><item><term>DMARD, disease modifying antirheumatic drug</term></item></list></keywords></textClass><textClass xml:lang="en"><keywords scheme="keyword"><list><head>KWD</head><item><term>decision tree</term></item><item><term>early rheumatoid arthritis</term></item><item><term>DMARD choice</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Immunology (including allergy)</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Biological agents</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Connective tissue disease</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Degenerative joint disease</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Drugs: musculoskeletal and joint diseases</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Musculoskeletal syndromes</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head>hwp-journal-coll</head><item><term>Rheumatoid arthritis</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2005-06-30">Created</change><change when="2006-01">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/fulltext.txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus bmj" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8" standalone="no"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Archiving and Interchange DTD v2.3 20070202//EN" URI="archivearticle.dtd" name="istex:docType"></istex:docType><istex:document><article xml:lang="en" article-type="other"><front><journal-meta><journal-id journal-id-type="hwp">annrheumdis</journal-id><journal-id journal-id-type="nlm-ta">Ann Rheum Dis</journal-id><journal-title>Annals of the Rheumatic Diseases</journal-title><abbrev-journal-title abbrev-type="publisher">Ann Rheum Dis</abbrev-journal-title><issn pub-type="ppub">0003-4967</issn><issn pub-type="epub">1468-2060</issn><publisher><publisher-name>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="other">0650045</article-id><article-id pub-id-type="doi">10.1136/ard.2005.035436</article-id><article-id pub-id-type="other">annrheumdis;65/1/45</article-id><article-id pub-id-type="other">annrheumdis;ard.2005.035436</article-id><article-id pub-id-type="pmid">15994280</article-id><article-id pub-id-type="other">45</article-id><article-id pub-id-type="other">ard.2005.035436</article-id><article-categories><subj-group subj-group-type="heading"><subject content-type="original">Extended reports</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Immunology (including allergy)</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Biological agents</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Connective tissue disease</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Degenerative joint disease</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Drugs: musculoskeletal and joint diseases</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Musculoskeletal syndromes</subject></subj-group><subj-group subj-group-type="hwp-journal-coll"><subject>Rheumatoid arthritis</subject></subj-group></article-categories><title-group><article-title>Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of Rheumatology</article-title></title-group><contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Le Loët</surname><given-names>X</given-names></name><xref rid="AFF1">1</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Berthelot</surname><given-names>J M</given-names></name><xref rid="AFF2">2</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Cantagrel</surname><given-names>A</given-names></name><xref rid="AFF3">3</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Combe</surname><given-names>B</given-names></name><xref rid="AFF4">4</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>De Bandt</surname><given-names>M</given-names></name><xref rid="AFF5">5</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Fautrel</surname><given-names>B</given-names></name><xref rid="AFF6">6</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Flipo</surname><given-names>R M</given-names></name><xref rid="AFF7">7</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Lioté</surname><given-names>F</given-names></name><xref rid="AFF8">8</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Maillefert</surname><given-names>J F</given-names></name><xref rid="AFF9">9</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Meyer</surname><given-names>O</given-names></name><xref rid="AFF10">10</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Saraux</surname><given-names>A</given-names></name><xref rid="AFF11">11</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Wendling</surname><given-names>D</given-names></name><xref rid="AFF12">12</xref></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Guillemin</surname><given-names>F</given-names></name><xref rid="AFF13">13</xref></contrib><aff id="AFF1"><label>1</label>Department of Rheumatology, Rouen University Hospital, Rouen, France</aff><aff id="AFF2"><label>2</label>Department of Rheumatology, Nantes University Hospital, Nantes, France</aff><aff id="AFF3"><label>3</label>Department of Rheumatology, Toulouse University Hospital, Toulouse, France</aff><aff id="AFF4"><label>4</label>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</aff><aff id="AFF5"><label>5</label>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</aff><aff id="AFF6"><label>6</label>Department of Rheumatology, La Pitié Paris University Hospital, Paris</aff><aff id="AFF7"><label>7</label>Department of Rheumatology, Lille University Hospital, Lille, France</aff><aff id="AFF8"><label>8</label>Department of Rheumatology, Lariboisière Paris University Hospital, Paris</aff><aff id="AFF9"><label>9</label>Department of Rheumatology, Dijon University Hospital, Dijon, France</aff><aff id="AFF10"><label>10</label>Department of Rheumatology, Bichat Paris University Hospital</aff><aff id="AFF11"><label>11</label>Department of Rheumatology, Brest University Hospital, Brest, France</aff><aff id="AFF12"><label>12</label>Department of Rheumatology, Besançon University Hospital, Besançon, France</aff><aff id="AFF13"><label>13</label>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</aff></contrib-group><author-notes><corresp>Correspondence to:
Professor Xavier Le Loët
Service de Rhumatologie, CHU–Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France; <ext-link xlink:href="xavier.le-loet@chu-rouen.fr" ext-link-type="email" xlink:type="simple">xavier.le-loet@chu-rouen.fr</ext-link></corresp></author-notes><pub-date pub-type="ppub"><month>1</month><year>2006</year></pub-date><pub-date pub-type="epub"><day>30</day><month>6</month><year>2005</year></pub-date><volume>65</volume><volume-id pub-id-type="other">65</volume-id><volume-id pub-id-type="other">65</volume-id><issue>1</issue><issue-id pub-id-type="other">annrheumdis;65/1</issue-id><issue-id pub-id-type="other">1</issue-id><issue-id pub-id-type="other">65/1</issue-id><fpage>45</fpage><history><date date-type="accepted"><day>19</day><month>05</month><year>2005</year></date></history><permissions><copyright-statement>Copyright 2006 by Annals of the Rheumatic Diseases</copyright-statement><copyright-year>2006</copyright-year></permissions><self-uri content-type="pdf" xlink:role="full-text" xlink:href="annrheumdis-65-45.pdf"></self-uri><abstract xml:lang="en"><p><bold>Objective:</bold> To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration.</p><p><bold>Methods:</bold> Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method.</p><p><bold>Results:</bold> Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity.</p><p><bold>Conclusions:</bold> Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.</p></abstract><kwd-group kwd-group-type="ABR" xml:lang="en"><kwd>DAS 28, 28 joint disease activity score</kwd><kwd>DMARD, disease modifying antirheumatic drug</kwd></kwd-group><kwd-group kwd-group-type="KWD" xml:lang="en"><kwd>decision tree</kwd><kwd>early rheumatoid arthritis</kwd><kwd>DMARD choice</kwd></kwd-group></article-meta></front></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Clinical practice decision tree for the choice of the first disease modifying antirheumatic drug for very early rheumatoid arthritis: a 2004 proposal of the French Society of 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France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">B</namePart><namePart type="family">Combe</namePart><affiliation>Federation of Rheumatology, Montpellier University Hospital, Montpellier, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">M</namePart><namePart type="family">De Bandt</namePart><affiliation>Department of Rheumatology, Bichat Paris University Hospital, Paris, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">B</namePart><namePart type="family">Fautrel</namePart><affiliation>Department of Rheumatology, La Pitié Paris University Hospital, Paris</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">R M</namePart><namePart type="family">Flipo</namePart><affiliation>Department of Rheumatology, Lille University Hospital, Lille, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">F</namePart><namePart type="family">Lioté</namePart><affiliation>Department of Rheumatology, Lariboisière Paris University Hospital, Paris</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">J F</namePart><namePart type="family">Maillefert</namePart><affiliation>Department of Rheumatology, Dijon University Hospital, Dijon, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">O</namePart><namePart type="family">Meyer</namePart><affiliation>Department of Rheumatology, Bichat Paris University Hospital</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">A</namePart><namePart type="family">Saraux</namePart><affiliation>Department of Rheumatology, Brest University Hospital, Brest, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">D</namePart><namePart type="family">Wendling</namePart><affiliation>Department of Rheumatology, Besançon University Hospital, Besançon, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">F</namePart><namePart type="family">Guillemin</namePart><affiliation>EA 344, Department of Public Health, Nancy University Hospital, Nancy, France</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="other" displayLabel="other" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-7474895G-0">other</genre><originInfo><publisher>BMJ Publishing Group Ltd and European League Against Rheumatism</publisher><dateIssued encoding="w3cdtf">2006-01</dateIssued><dateCreated encoding="w3cdtf">2005-06-30</dateCreated><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">Objective: To elaborate a clinical practice decision tree for the choice of the first disease modifying antirheumatic drug (DMARD) for untreated rheumatoid arthritis of less than six months’ duration. Methods: Four steps were employed: (1) review of published reports on DMARD efficacy against rheumatoid arthritis; (2) inventory of the information available to guide DMARD choice; (3) selection of the most pertinent information by 12 experts using a Delphi method; and (4) choice of DMARDs in 12 clinical situations defined by items selected in step 3 (28 joint disease activity score (DAS 28): ⩽3.2; >3.2 and ⩽5.1; >5.1; rheumatoid factor status (positive/negative); structural damage (with/without)—that is, 3×2×2). Thus, multiplied by all the possible treatment pairs, 180 scenarios were obtained and presented to 36 experts, who ranked treatment choices according to the Thurstone pairwise method. Results: Among the 77 items identified, 41 were selected as pertinent to guide the DMARD choice. They were reorganised into five domains: rheumatoid arthritis activity, factors predictive of structural damage; patient characteristics; DMARD characteristics; physician characteristics. In the majority of situations, the two top ranking DMARD choices were methotrexate and leflunomide. Etanercept was an alternative for these agents when high disease activity was associated with poor structural prognosis and rheumatoid factor positivity. Conclusions: Starting with simple scenarios and using the pairwise method, a clinical decision tree could be devised for the choice of the first DMARD to treat very early rheumatoid arthritis.</abstract><note type="author-notes">Correspondence to:
Professor Xavier Le Loët
Service de Rhumatologie, CHU–Hôpitaux de Rouen, 1 rue de Germont, 76031 Rouen Cedex, France; xavier.le-loet@chu-rouen.fr</note><subject lang="en"><genre>ABR</genre><topic>DAS 28, 28 joint disease activity score</topic><topic>DMARD, disease modifying antirheumatic drug</topic></subject><subject lang="en"><genre>KWD</genre><topic>decision tree</topic><topic>early rheumatoid arthritis</topic><topic>DMARD choice</topic></subject><relatedItem type="host"><titleInfo><title>Annals of the Rheumatic Diseases</title></titleInfo><titleInfo type="abbreviated"><title>Ann Rheum Dis</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><subject><genre>hwp-journal-coll</genre><topic>Immunology (including allergy)</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Biological agents</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Connective tissue disease</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Degenerative joint disease</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Drugs: musculoskeletal and joint diseases</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Musculoskeletal syndromes</topic></subject><subject><genre>hwp-journal-coll</genre><topic>Rheumatoid arthritis</topic></subject><identifier type="ISSN">0003-4967</identifier><identifier type="eISSN">1468-2060</identifier><identifier type="PublisherID-hwp">annrheumdis</identifier><identifier type="PublisherID-nlm-ta">Ann Rheum Dis</identifier><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>65</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>45</start></extent></part></relatedItem><identifier type="istex">FCE32DE33991918A6405865080D3DF7C30A1993A</identifier><identifier type="ark">ark:/67375/NVC-F4VXKQT6-1</identifier><identifier type="DOI">10.1136/ard.2005.035436</identifier><identifier type="href">annrheumdis-65-45.pdf</identifier><identifier type="PMID">15994280</identifier><identifier type="local">0650045</identifier><accessCondition type="use and reproduction" contentType="copyright">Copyright 2006 by Annals of the Rheumatic Diseases</accessCondition><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-7M42M2QJ-2">bmj</recordContentSource><recordOrigin>Copyright 2006 by Annals of the Rheumatic Diseases</recordOrigin></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/record.json</uri></json:item></metadata><annexes><json:item><extension>jpeg</extension><original>true</original><mimetype>image/jpeg</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-F4VXKQT6-1/annexes.jpeg</uri></json:item></annexes><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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