One-Year Outcomes After Decision Aid-Led Tapering of Advanced Therapy in Rheumatoid Arthritis
Notice bibliographique
Résumé
Objectives The Canadian Rheumatology Association clinical practice guidelines recommend offering tapering of advanced therapy to people with rheumatoid arthritis (RA) who are in sustained remission and provide a decision aid to support these discussions. Our goal was to understand the impact of implementing the decision aid on treatment choices and outcomes in RA patients in sustained remission. Methods We conducted a single-center pilot study with 4 rheumatologists in Calgary Alberta. Rheumatologists were initially asked to identify people in their practice at the time of the clinic visit. After identifying and addressing initial recruitment barriers, we switched to sending people a decision aid 1 month ahead of their appointment. While rheumatologists and patients were free to decide how fast to taper, and when to see their rheumatologist next, they were guided by CRA recommendations, which suggested decreasing the dose by ~25% at a time, with 3-month delays between subsequent reductions. Patients were followed for a year and the primary outcome (safety) was the proportion of patients who had to switch to another advanced therapy due to inefficacy. Results Thirty-four patients chose to taper their advanced therapy; 13 from in-clinic discussions, and 21/83 (25%) who received a decision aid ahead of their appointment. Of the 34 people, 32 consented to the follow-up study (mean age 55, 72% female). All patients were taking full dose advanced therapy at the time of recruitment. Patients reduced their TNF inhibitor (n=19), IL-6-blocker (n=5) JAK-inhibitor (n=4), and T-cell inhibitor (n=4). Among the 26 patients who have completed follow-up to date (last follow-up October 2024), 8 (31%) had a flare requiring re-escalation of their dose, and another 3 (12%) re-escalated their dose for other reasons (typically discomfort with being on a lower dose and the potential to have a flare). One patient switched to another agent without first re-escalating their dose. Of the 15 patients who maintained a dose reduction over 1 year, the mean dose reduction at 1 year was 47%. Of the 9 patients who re-escalated their dose after tapering and have completed the end of study survey, 8 (89%) agreed or strongly agreed with the statement “I am glad I tried reducing my medication.” The remaining patient was neutral. Conclusion Sending people a guideline-linked decision aid ahead of their appointment resulted in 25% of people choosing to reduce their treatment, which was safe for over 1 year, and without decisional regret in people who had to re-escalate their dose.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,004 | 0,007 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,002 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,001 | 0,001 |
| Science ouverte | 0,001 | 0,001 |
| Intégrité de la recherche | 0,001 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».