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Autoimmune Diseases Rheumatoid Arthritis
clinic. The effectiveness and cost-effectiveness of the anti-TNF All patients answer the last five questions of the survey, which are
treatments were calculated based on the cost of therapy required to related to productivity limitations at home and participation in family,
achieve a change in HAQ score of minimal clinical significance. social and leisure activities over the previous month. These five
questions comprise the following:
HAQ is considered to be an excellent predictor of work disability as well
as morbidity and mortality.
45
HAQ scores decreased with treatment and • number of days with no household work performed due to arthritis;
were sustained throughout the three to five years of follow-up. The • days with household productivity reduced by ≥50% (does not
findings suggested that approximately two patients needed to be include days counted in the previous question);
treated in order to gain clinically meaningful improvements in HAQ in all • days with outside help hired;
three disease phenotypes. Longer follow-up studies in established RA • rate of interference with household productivity by RA on a 0–10
are needed to determine the long-term effect on work disability and the scale; and
true cost-effectiveness of TNF inhibitors over time when calculated with • days in which family, social or leisure activities are missed.
respect to employment status, associated income tax revenue, the cost
of benefits, payments to carers and other related expenses. The WPS-RA was found to be a valid, reliable instrument that was able
to discriminate between subjects with different RA symptom severities
The potential work-related benefits of early optimisation of therapy and responsive to recognised clinical changes. These properties were
with early intervention with etanercept have recently been reported evaluated in patients with active RA enrolled in the eFficAcy and Safety
in the context of a double-blind, randomised clinical trial: COmbination of cerTolizumab pegol—4 Weekly dosAge in RheumatoiD arthritis (FAST
of Methotrexate and Etanercept in early rheumatoid arthritis Trial 4WARD) study. FAST 4WARD was a 24-week double-blind, placebo-
(COMET).
46
The effects of etanercept 50mg once-weekly plus MTX controlled phase III study.
47
Notably, the WPS-RA survey has only been
versus MTX alone were compared with respect to achievement of used in studies with certolizumab pegol.
clinical remission. The relationship between patient-reported outcomes
and improvement was also investigated. Close relationships between Certolizumab Pegol, Work and
disease activity and improvements in patient-reported outcomes were Household Productivity
observed. In particular, significantly fewer patients assigned to Certolizumab pegol is the only PEGylated anti-TNF agent developed for
treatment with etanercept plus MTX (9%) reported first-time work the treatment of RA. Studies with this biologic agent have shown clinical
stoppage compared with the MTX monotherapy group (24%). In benefits in reducing the signs and symptoms of RA, as well as inhibiting
agreement with other studies, these findings convey a consistent the progression of structural joint damage.
8,9
Moreover, there is growing
message regarding anti-TNF biologics, suggesting that early treatment evidence that certolizumab pegol as add-on therapy to MTX can
with remission as a goal should maximise the chance of restoring improve physical function and health-related quality of life, as well as
normal functioning and health-related quality of life measures. work and household productivity.
Measuring Productivity Within and Outside the This was shown by recent results from the RA PreventIon of Structural
Home and Daily Activities Damage (RAPID) 1 and 2 studies.
8,9
In these two multicentre, randomised,
There are few studies in established RA that have specifically double-blind, placebo-controlled phase III studies, workplace and home
investigated the effect of therapeutic intervention with biologic anti- productivity and family, social and leisure activities were assessed using
TNF agents on household work productivity and improvement in the WPS-RA at baseline and every four weeks until the end of the study
participation in family and social activities. In order to undertake or until study withdrawal.
48
At baseline, 41.6% (RAPID 1) and 39.8%
such studies, validated tools are required; one such tool has (RAPID 2) of subjects in the intention-to-treat population were employed
recently been reported. outside the home. On average, patients in both trials who were working
reported having to miss 2.8–4.6 working days a month due to their RA
The RA-specific Work Productivity Survey (WPS-RA) is a novel and had 6.2–9.2 working days per month in which productivity was
validated questionnaire.
47
It was developed to assess the impact of RA reduced by more than 50%. Among patients working outside the home,
on productivity in terms of paid work outside the home, work within there were significant reductions in absenteeism and presenteeism in
the home and family, social and leisure activities over the preceding those subjects treated with certolizumab pegol plus MTX compared
month. The WPS-RA is based on self-report and is interviewer- with placebo plus MTX. At week 4 in RAPID 1, patients treated with
administered. The survey consists of nine questions. certolizumab pegol 200mg plus MTX every other week reported an
average of 1.5 work days missed per month, 4.3 days of reduced
The first question addresses employment status and provides productivity and a monthly rate of RA interference with work
additional information on job type for employed subjects and the productivity of 3.5 (0–10 scale). By comparison, patients receiving
status of those not employed. placebo plus MTX reported 2.5 days of absenteeism, 6.5 days of
presenteeism and a rate of RA interference of 4.2. At week 52, the
For employed patients only, three questions assess: figures for absenteeism were 1.0 day missed per month for patients
treated with certolizumab pegol 200mg plus MTX every other
• absenteeism, defined as full days of work missed due to arthritis; week versus 4.5 days for patients treated with placebo plus MTX
• presenteeism, defined as days with work productivity in the (p≤0.05), presenteeism was 2.1 days per month versus 4.4 days (p≤0.05)
workplace reduced by ≥50% due to arthritis (excluding days and the rate of RA interference with active treatment was significantly
qualifying as absenteeism); and lower than placebo (5.2 versus 2.4; p≤0.05). In RAPID 2 at week 24, the
• rate of interference with work productivity by RA on a 0–10 scale corresponding numbers were 1.3 and 2.5 days, respectively, for
(0 = no interference; 10 = complete interference). absenteeism (p=NS), 3.1 and 9.3 days, respectively for presenteeism
38 EUROPEAN MUSCULOSKELETAL REVIEW
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