Cost versus benefit: a treatment audit

  • T. Price


Despite a slightly increased mortality at all ages, the average lifespan of patients with rheumatoid disease is little reduced and the majority will suffer from their arthritis for at least twenty-five years.

The prevalence of this condition has been estimated to be about 2-3 per cent. This high figure conceals different patterns of disease. There are some patients who experience a brief illness with early remission and apparent recovery; in others, gradual functional deterioration over the years is punctuated by a series of remissions and relapses. The pattern of illness may, on the other hand, be progressive with a course that does not seem to be appreciably altered by drug therapy. There is also a minority of, mainly, elderly patients who develop a malignant form of disease with a particularly aggressive and disabling arthritis, leading rapidly to severe handicap.

Treatment should ideally take account of the likely outcome of the illness. For those with the most aggressive disease, powerful and potentially toxic drugs may be appropriate and even radiotherapy may be justified as a part of controlled studies. To give such treatments to a patient who may have been destined to recover however, would be unfortunate, especially as there may be a long-term risk of adverse effects.

Recent studies have shown that only a small proportion of patients prescribed second-line drugs remain on treatment with any one agent for more than four years; the figure may be as low as 15 per cent. A second disease-modifying drug, given following failure of the first, may fare even less well. For patients who show sustained improvement on such drugs, the benefits are unequivocal. This minority, however, must be weighed against the majority whose treatment has to be discontinued. Of the latter, approximately half will have stopped their drugs because of side-effects, which range from the unpleasant to the life-threatening. The remainder will have had to contend with repeated clinic visits and blood tests in order to receive treatment that is at best inefficacious and at worst, dangerous.

As Duthie has shown, functional capacity can be maintained in a majority of patients using a conservation rehabilitation regime without recourse to second line drugs. If we are to continue to use these agents it is imperative that we learn how to use them more efficiently. We must know what constitutes a good or a poor prognosis, who is likely to respond to what treatment and who is most likely to suffer side-effects from the drugs. At present we may be over-treating those with a good prognosis, whilst those with a poor outlook may still be receiving inadequate or inappropriate therapy.


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© D. H. Goddard and R. C. Butler 1984

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  • T. Price

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