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(city)-states and Israel, which were excluded from the start, and the easier the access. Criteria for stop/maintenance (at 6
Kyrgyzstan, where it turned out to be impossible to establish months), switch and change of frequency/dose were also cate-
collaboration.4 gorised after inspection into broad groups to reect the patterns
Data on the eligibility for initiation and maintenance/stop or (table 3).
switches between bDMARDs in patients with RA were collected,
as of May 2011, by a rheumatologist or an expert from each Statistical analysis
country. Answers were carefully checked and collaborators were Data were analysed for all countries using descriptive statistics.
contacted to conrm the results. Score on the individual criteria (original values) and composite
First, experts were asked whether at least one bDMARD was index were compared between the 27 EU and the 9 non-EU
reimbursed. For those countries conrming an ofcial reim- countries by means of MannWhitney U test (skewed
bursement, medical specialties authorised to prescribe biologics distribution).
to patients with RA were identied, as well as whether either The association between the sources of prevailing regulation
reimbursement criteria or clinical recommendations (or both) (only reimbursement criteria, only clinical recommendations or
were predominantly regulating prescription. Further, informa- both) and the frequency of controls on prescriptions from the
tion was collected on the following requirements before starting regulating agencies was investigated through 2 test.
a bDMARD (if applicable): (a) minimal disease duration; (b) Correlations (Spearman) were rst established between the
failure of synthetic DMARDs (sDMARDs), including type, individual criteria for initiation of a rst bDMARD and, next,
number and length of treatment; and (c) clinical criteria, such as between the crude individual criteria and the composite score
level of disease activity where applicable (eg, disease activity with (a) indicators of socioeconomic welfare; (b) uptake of
score with 28-joint assessmentDAS287). Finally, questions bDMARDs; and (c) indicators of RA health status. Analysis was
were asked on (a) time point to assess response; (b) require- done for all countries and EU countries separately. Coefcients
ments to alter the frequency and/or dose of a biologic; (c) cri- >0.5 but 0.80 were assumed to be moderate and >0.8
teria to stop (or maintain, as reported) therapy with biologics; strong.13 SPSS V.19.0 was used.
(d) criteria to switch between agents; (e) existence and (if applic-
able) frequency of ofcial controls on the adherence to the RESULTS
reimbursement criteria; and (f ) maximum number of biologics In total, 46 countries (response rate 94%) provided data. An
that could be tried on one patient. overview of the clinical criteria for eligibility and maintenance
of biologic in each of the countries is presented in table 1. In 10
Data on indicators of socioeconomic welfare and health countries (22%), no bDMARD was reimbursed. Among the
status of RA patients remaining 36, Luxemburg had no regulation for the start of a
Data on the number of inhabitants and indicators of socio- reimbursed bDMARD, in 11 (31%) reimbursement criteria were
economic welfare (gross domestic product (GDP), total health the major source of eligibility criteria, while in 7 (19%) clinical
expenditure and median income) were collected for each recommendations predominated and in 16 (44%) both reim-
country. Values were retrieved from web-based sources (latest bursement criteria and clinical recommendations were used
available data for 20082011) and adjusted to purchasing power (usually because they were similar or clinical criteria comple-
parities (2010, expressed in international dollars, int.$).810 mented reimbursement criteria) for decisions to start a biologic
Data on RA health status and uptake of bDMARD ( percent- (table 1). Albania had no written source of regulation but
age of patients ever treated with a biologic) were available for reported the criteria used in practice. Countries differed with
21 countries from the Quantitative Standard Monitoring of respect to frequency of controls of the adherence to formal
Patients with RA (QUEST RA) study, a multinational cross- recommendations. Thirteen countries (36%) reported controls
sectional study of non-selected outpatients with RA on disease were frequent or always, in 17 countries (47%) controls were
outcome. This provided clinical information: DAS28; swollen rare or sometimes and respondents from six countries (17%)
joint count; tender joint count; Health Assessment reported no controls of adherence to existing criteria. No asso-
Questionnaire11; Physician (MD) and Patient (PT) Global Visual ciation between the type of prevailing regulation (ie, reimburse-
Analogue Scales and erythrocyte sedimentation rate.5 12 ment criteria, clinical recommendations or both) and reported
frequency of controls was detected ( p=0.43).
Computed variables and composite score for clinical In 24 countries (67%), only rheumatologists had permission
eligibility criteria to prescribe bDMARDs to patients with RA, while in the rest
The individual criteria to assess eligibility for a rst biologic other specialties such as Dermatology (22%), Gastroenterology
(disease duration, disease activity level and number of (22%), Internal medicine (25%), General practice (11%) and
sDMARDs to be failed) were inspected and categorised into two other (14%) were similarly entitled to prescribe (table 1).
or three broad groups so that the most frequent patterns could Among 36 countries with at least one biologic reimbursed, 23
be identied (tables 1 and 2). In order to compute this compos- (64%) had no requirement on disease duration to initiate a
ite score, requirement for a specic disease duration was cate- bDMARD, while for the remaining countries the prespecied
gorised as any requirement (0 point) or no requirement (1 minimum duration ranged from 3 to 12 months. With respect to
point); the number of sDMARDs to be failed as more than the number of sDMARDs to be failed, the most common criter-
two (0 point), two (1 point) and less than two(2 points) and ion (n=18(50%)) was the failure of two DMARDs. A minimum
the level of disease activity (based on the level of DAS28 since level of disease activity or severity was mandatory in 31 (86%)
this appeared to be the criterion applied by most regulations) as countries but was not specied in Germany, Ireland, Luxemburg,
DAS28 cut-off >3.2 or its equivalent (0 point), DAS28 cut-off Malta and Switzerland. In 11 countries (31%), patients with a
3.2 or its equivalent (1 point) and no requirement (2 DAS28 of 3.2 qualied to obtain access to bDMARDs, but in 20
points). In addition, a composite score was computed for each countries (ie, over 50%) this requirement was stricter than a
country, which was the simple sum of the scores on the individ- DAS28 of 3.2 (or equivalent), meaning that the cut-off to start a
ual criteria and varied between 0 and 5; the higher the score, biologic was higher than 3.2 (tables 1 and 2).
Table 1 Clinical criteria for eligibility and maintenance of treatment with bDMARDs in 36 European countries with at least one biologic reimbursed
Albania (no written REIM Rheumatology No requirement DAS28>4.5 2 sDMARDs: MTX NA No criteria No criteria 2
source provided, (20 mg/week) and SSZ
criteria reported are (2.5 g/day)
those used in
Table 1 Continued
Requirement to start the first biologic Time point for Composite score
the first for
Major source Who can prescribe Minimum Number of sDMARDs assessment of Criteria to restrictiveness of
of eligibility bDMARDs to disease to be failed, type of response stop at Criteria to switch at clinical criteria
Country criteria patients with RA duration Level of disease activity DMARD and length (weeks) 6 months* 6 months* (05)
Continued
2014
Lithuania4749 REIM=GUID Rheumatology No requirement DAS28>5.1 2 sDMARDs: choice MTX 12 Improvement in Improvement in DAS28 2
(25 mg/week) for DAS28 <1.2 <1.2 after 3 months
3 months, AZATH after 3 months
Table 1 Continued
Requirement to start the first biologic Time point for Composite score
the first for
Major source Who can prescribe Minimum Number of sDMARDs assessment of Criteria to restrictiveness of
of eligibility bDMARDs to disease to be failed, type of response stop at Criteria to switch at clinical criteria
Country criteria patients with RA duration Level of disease activity DMARD and length (weeks) 6 months* 6 months* (05)
Serbia58 59 REIM+GUID Rheumatology 6 months Immediate and high activity 2 sDMARDs: MTX 1216 No criteria Improvement in DAS28 1
(ACR IIII/DAS28>5.1 AND HAQ (7.5 mg/week) for at <1.2
No 23 (64%) AL, AT, BE, DK, FI, FR, DE,GR, IS, IE, LV, 1 No requirement 5 (14%) DE, IE, LU, MT and CH 2 <2 14 (39%) AT, CZ, FR, DE, IS, IE, IT, LU, NO, PT, 2
requirement LT, LU, MK, NL, NO, PT, RO, SL, ES, SE, SK, ES, SE and CH
Table 3 Summary of clinical eligibility criteria for stop of the therapy, switch to another bDMARD or change frequency/dose of a biologic for European countries with at least one biologic
reimbursed (n=36)
Stop due to inefficacy based on 6 -month assessment Switch based on 6-month assessment Change of frequency/dose
Not specified 22 (61%) AL, AT, BG, CZ, DK, FI, FR, DE, IS, Not specified 17 (47%) AL, BE, BG, HR, DK, FI, FR, Not 18 (50%) AL, AT, BE, BG, HR, EE, FI,
IE, IT, LV, LU, MK, ME, NO, RO, DE, IE, IT, LU, MK, MT, NO, specified FR, DE, LV, LU, ME, NL, PL,
RS, SK, ES, SE and CH SL, CH and TR PT, SE, UK and MK
Yes, in terms of DAS283.2 5 (14%) CY, MT, HR, HU and BE Yes, in terms of disease DAS283.2 6 (17%) CY, GR, IS, LV, ES and SE Yes, 15 (42%) CY, CZ, DK, GR, IS, IE, IT,
disease activity level 7 activity level 11 (31%) DAS28>4.6 1 (3%) EE frequency MT, NO, RO, RS, SL, ES, CH
(19%) and TR
DAS28>5.1 1 (3%) RO Yes, dose 18 (50%) CY, CZ, DK, GR, IS, IE, IT, LT,
Moderate 3 (8%) AT, CZ and SK MT, NO, RO, RS, SK, SL, ES,
disease activity CH, TR and HU
Yes, in terms of DAS28 <0.6 1 (3%) BE Yes, in terms of DAS28 <0.6 in 1 (3%) PT
improvement 14 (39%) improvement10 (28%) 3 months
<1.2 14 (39%) BE, HR, CY, EE, GR, HU, MT, NL, <1.2 10(28%) CY, HU, LT, ME, NL, PL,
PT, SL, TR, UK, LT and PL PT, RO, RS and UK
*Countries could have more than one criterion to stop/switch (disease activity level and/or disease activity improvement).
Additional clinical criteria have to be satisfied besides the specified level of DAS28, for example, additional requirement for radiographic damage or specific levels of swollen joint count and/or total joint count.
If DAS28>5.1.
After 3 months.
bDMARD, biologic disease-modifying antirheumatic drugs; DAS28, disease activity score with 28-joint assessment.
AL, Albania; AT, Austria; BE, Belgium; BG, Bulgaria; CH, Switzerland; CY, Cyprus; CZ, Czech Republic; DE, Germany; DK, Denmark; EE, Estonia; ES, Spain; FI, Finland; FR, France; GR, Greece; HR, Croatia; HU, Hungary; IE, Ireland; IS, Iceland; IT, Italy; LT,
Lithuania; LU, Luxemburg; LV, Latvia; ME, Montenegro; MK, Macedonia; MT, Malta; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; RO, Romania; RS, Serbia; SE, Sweden; SK, Slovakia; SL, Slovenia; TR, Turkey; UK, United Kingdom.
Downloaded from http://ard.bmj.com/ on October 27, 2014 - Published by group.bmj.com
The timing for the rst assessment of response was specied minimum level of disease activity (n=11, 31%) and/or failure
in 29 countries and varied from 9 to 24 weeks, with 16 coun- to reach a minimum improvement in disease activity (n=10,
tries dening this period as 12 weeks. Fourteen countries (39%) 28%). Half of the countries (n=18, 50%) had some regulation
reported to have specic criteria to stop bDMARD before or at regarding the possibility to change the frequency and/or dose
6 months due to inefcacy (or for maintenance, from which of a biologic (table 3). So far, no country introduced a
stop criteria were extrapolated) (table 3). Of those, 11 (31%) maximum number of biologics that can be prescribed to one
required a minimum improvement in terms of disease activity patient.
(improvement of 1.2) before or at 6 months for therapy to be As for the composite score for clinical eligibility criteria that
continued. Five of these countries (14%) required in addition a was based on the three criteria to initiate a bDMARD, 4 coun-
prespecied minimum level of disease activity to be achieved tries (11%) had the maximum (5) eligibility score (most liberal),
and this level corresponded to low disease activity (ie, DAS28 of 12 countries (33%) had score 3 or 4 and 20 (56%) scored
3.2) in four of them. between 0 and 2. Countries from Eastern Europe and Former
More than half of the countries (n=19, 53%) reported there Soviet Union were more likely to be classied in the more
were specic criteria for switching. These criteria included a restricted scores (table 1, gure 1).
Figure 1 Composite score for restrictiveness of clinical criteria for initiation of a rst reimbursed biologic (05) in the European Region (score is
composed of (1) minimum required disease duration, (2) number of sDMARDs that have to be failed and (3) the level of DAS28). DAS28, disease
activity score with 28-joint assessment; sDMARDs, synthetic disease-modifying antirheumatic drugs.
AL, Albania; AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CY, Cyprus; CZ, Czech Republic; EE, Estonia; FI, Finland; FR, France; DE, Germany;
DK, Denmark; GR, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LT, Lithuania; LU, Luxemburg; MK, Macedonia; MT, Malta;
ME, Montenegro; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; RO, Romania; RS, Serbia; SK, Slovakia; SL, Slovenia; ES, Spain;
SE, Sweden; CH, Switzerland; TR, Turkey; UK, United Kingdom.
The results for the eligibility for a rst bDMARD did not DISCUSSION
differ signicantly between the 27 EU and 9 non-EU members, This study highlights differences in clinical criteria that regulate
neither for the individual criteria nor for the composite score initiation and continuation of treatment with reimbursed
(data not shown). bDMARDs in patients with RA across the European Region. A
rst and foremost nding was that in 10 countries (all non-EU)
no bDMARDs were reimbursed. In countries with bDMARDs
reimbursed (n=36), criteria mainly regulated the start of the
Correlation of clinical criteria and composite score for the rst biologic (all countries) in contrast with regulations for stop-
eligibility for rst biologic with GDP, uptake of bDMARDs ping/maintaining (n=14, 39%) or switching between drugs
and health status (n=19, 53%), which were not dened in every country. Limited
The three individual clinical criteria to start a bDMARD were regulations to stop bDMARDs are remarkable, because substan-
positively but weakly correlated with each other (Spearman tial costs can potentially be saved by stopping costly drugs that
coefcients 0.230.43), with the strongest association between are (or have become) ineffective. On this line it is interesting to
the required level of disease activity and the number of see that several new studies explore the impact of stopping
sDMARDs to be failed (data not shown). bDMARDs in patients with sustained remission.14
The level of DAS28 required before starting a bDMARD was Strikingly, in more than half of the countries (56%) the
moderately negatively associated with socioeconomic indicators cut-off for the DAS28 as a criterion to start the rst biologic
(gure 2), weakly positively with the indicators of health status was stricter than 3.2 (DAS283.2). Furthermore, 13 countries
of RA patients and weakly negatively with the uptake of (36%) required a minimum disease duration and 22 (61%) spe-
bDMARDs. The number of sDMARDs to be failed and require- cied that more than one sDMARDs had to be failed before a
ment for minimum disease duration followed similar patterns bDMARD can be initiated.
(table 4). Overall, the composite eligibility score indicated highly
The composite score was moderately positively associated restricted access in one-third of the countries (scores 0 and 1). A
with socioeconomic welfare and weakly to moderately nega- strong negative association between the eligibility and GDP was
tively with the indicators of health status. Importantly, the com- found. Particularly non-EU countries had stricter eligibility cri-
posite score correlated moderately positively with the available teria. In many of these countries the eligibility criteria tended to
data on the uptake of biologics. When analyses were limited to be stricter than The European League Against Rheumatism
the 27 EU member states, correlations were weaker but the dir- (EULAR) recommendations and were not following the
ection of the associations persisted (table 4). treat-to-target recommendations.15 16
Figure 2 Composite score for restrictiveness of clinical criteria (05) and GDP per capita (int/$), n=36. Size of the bubble is proportional to the
population size of each country. Dashed trend line is added to show the linear trend if without data from Luxemburg, which can be considered an
outlier GDP, gross domestic product.
AL, Albania; AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CY, Cyprus; CZ, Czech Republic; EE, Estonia; FI, Finland; FR, France; DE, Germany;
DK, Denmark; GR, Greece; HU, Hungary; IS, Iceland; IE, Ireland; IT, Italy; LV, Latvia; LT, Lithuania; LU, Luxemburg; MK, Macedonia; MT, Malta; ME,
Montenegro; NL, the Netherlands; NO, Norway; PL, Poland; PT, Portugal; RO, Romania; RS, Serbia; SK, Slovakia; SL, Slovenia; ES, Spain; SE, Sweden;
CH, Switzerland; TR, Turkey; UK, United Kingdom.
bDMARD, biologic disease-modifying antirheumatic drug; DAS28, disease activity score with 28-joint assessment; ESR, erythrocyte sedimentation rate; GDP, gross domestic product; HAQ, Health Assessment Questionnaire; MD, medical doctor; PT, patient;
Table 4 Correlations between clinical eligibility criteria, national indicators of socioeconomic development and health status indicators of patients with RA in 36 countries of the European Region
Region, thus providing more comprehensive picture regarding
bDMARDs ever, % of
Uptake of bDMARDs
patients n=1618
the regulations of prescriptions of bDMARDs as compared with
previous studies.6 17 Second, geographic variations in criteria
0.58 (0.60)
0.31 (0.21)
0.70 (0.68)
0.79 (0.72)
regulating initiation of a rst biologic were seen in their relation
to countries socioeconomic welfare, which expanded on study
previously reported by Pease et al.17
Within the limitations of availability and generalisability of
0.48 (0.40)
0.33 (0.32) data on medication uptake and RA health status across coun-
0.40 (0.33)
0.28 (0.15)
tries, our ndings are alarming as stricter clinical eligibility cri-
n=1720
*First value corresponds to Spearman correlation between both variables in all the 36 countries and the second value refers to the same correlation but within those countries that are from the European Union.
ESR
non-EU countries.
0.33 (0.27)
0.33 (0.24)
0.27 (0.24)
0.11 (0.05)
n=1720
0.41 (0.36)
0.23 (0.19)
n=1720
0.36 (0.35)
0.18 (0.21)
MD Global
n=1720
RA, rheumatoid arthritis; sDMARDs, synthetic disease-modifying antirheumatic drugs; TJC, tender joint count; VAS, Visual Analogue Scale.
0.47 (0.33)
0.26 (0.25)
0.19 (0.22)
0.36 (0.29)
0.17 (0.13)
n=1720
not take into account the regional variations that can exist
DAS28
0.34 (0.4)
Total health
0.72 (0.66)
0.50 (0.45)
0.60 (0.55)
0.46 (0.37)
0.41 (0.48)
0.61 (0.49)
0.56 (0.47)
0.70 (0.63)
n=2736
Number of sDMARDs to be
increasingly inuenced by pure nancial considerations, and 3 Pronk MH, Bonsel GJ. Out-patient drug policy by clinical assessment rather than
patients in countries with lower budgets have stricter clinical nancial constraints? The gate-keeping function of the out-patient drug
reimbursement system in The Netherlands. Eur J Health Econ 2004;5:2747.
requirements to initiate a treatment that would be clinically 4 Putrik P, Ramiro S, Kvien TK, et al. Inequities in access to biologic and synthetic
recommended at earlier stage. However, the problem is DMARDs across 46 European countries. Ann Rheum Dis 2014;73:198206.
complex and has to be treated within the national priorities on 5 Sokka T, Kautiainen H, Pincus T, et al. Disparities in rheumatoid arthritis disease
public health agenda. activity according to gross domestic product in 25 countries in the QUEST RA
database. Ann Rheum Dis 2009;68:166672.
6 Emery P, Van Vollenhoven R, Ostergaard M, et al. Guidelines for initiation of
Author afliations anti-tumour necrosis factor therapy in rheumatoid arthritis: similarities and
1
Department of Health Promotion and Education, Maastricht University, School for differences across Europe. Ann Rheum Dis 2009;68:4569.
Public Health and Primary Care (CAPHRI), Maastricht, The Netherlands 7 Prevoo ML, van t Hof MA, Kuper HH, et al. Modied disease activity scores that include
2
Department of Clinical Immunology & Rheumatology, Academic Medical Center, twenty-eight-joint counts. Development and validation in a prospective longitudinal
University of Amsterdam, Amsterdam, The Netherlands study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38:448.
3
Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal 8 The World Bank. [cited 2011 October 26th]; http://www.worldbank.org/
4
Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway 9 European health for all database (HFA-DB). [cited 26th October 2011]; http://data.
5
Department of Medicine, Jyvskyl Central Hospital, Jyvaskyla, Finland euro.who.int/hfadb/
6
Department of Rheumatology, National Research Center for Rehabilitation in 10 European Comission (EUROSTAT). [cited 26th October2011]; http://epp.eurostat.ec.
Rheumatology, Diakonhjemmet Hospital, Oslo, Norway europa.eu/portal/page/portal/eurostat/home/
7
Department of Internal Medicine, Division of Rheumatology, Maastricht University 11 Fries JF, Spitz P, Kraines RG, et al. Measurement of patient outcome in arthritis.
Medical Center and School for Public Health & Primary Care (CAPHRI), University Arthritis Rheum 1980;23:13745.
Maastricht, Maastricht, The Netherlands 12 Sokka T, Kautiainen H, Toloza S, et al. QUEST-RA: quantitative clinical assessment
of patients with rheumatoid arthritis seen in standard rheumatology care in
Acknowledgements We acknowledge all the individuals with whom we discussed 15 countries. Ann Rheum Dis 2007;66:14916.
the ideas presented in this manuscript and who have helped us in any way to 13 Zou KH, Tuncali K, Silverman SG. Correlation and simple linear regression.
complete this project. In particular, we express our gratitude to Argjent Tafaj Radiology 2003;227:61722.
(Albania), Louis Van Praet (Belgium), Sevdalina Lambova (Bulgaria), Ulla Ege 14 van den Broek M, Lems WF, Allaart CF, et al. Do we need guidelines to stop as
Johansen (Denmark), Laszlo Gulacsi (Hungary), Oliver FitzGerald (Ireland), Casabella well as to start biological therapies for rheumatoid arthritis? Clin Exp Rheumatol
Andrea (Italy), Liliana Groppa (Moldova), Piotr Guszko (Poland), Ruxandra Ionescu 2012;30:S216.
(Romania), Jozef Rovensky (Slovakia), Elisabet Lindqvist (Sweden) and Oleg 15 Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the
Nadashkevich (Ukraine). management of rheumatoid arthritis with synthetic and biological disease-modifying
Contributors AB conceived the idea for the article and outlined the study design; antirheumatic drugs. Ann Rheum Dis 2010;69:96475.
PP, SR, TK, TS, TU and AB contributed to data collection; PP, SR and AB were 16 Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target:
involved in data analysis and interpretation. Figures were developed by PP, SR and recommendations of an international task force. Ann Rheum Dis 2010;69:6317.
AB, and the manuscript was drafted by PP, SR, TK, TU and AB. All authors have 17 Pease C, Pope JE, Truong D, et al. Comparison of anti-TNF treatment initiation in
critically reviewed the nal draft. rheumatoid arthritis databases demonstrates wide country variability in patient
parameters at initiation of anti-TNF therapy. Semin Arthritis Rheum 2011;41:819.
Collaborators All members of Working Group Equity in Clinical Eligibility Criteria
18 Neovius M, Sundstrom A, Simard J, et al. Small-area variations in sales of TNF
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Helga Radner (Austria), Nikolay Soroka (Belarus), Herman Mielants (Belgium), Sekib
19 Mercuri M, Natarajan MK, Norman G, et al. An even smaller area variation:
Sokolovic (Bosnia and Herzegovina), Lyubomir Sapundzhiev (Bulgaria), Miroslav
differing practice patterns among interventional cardiologists within a single high
Mayer (Croatia), Paraskevi Charalambous (Cyprus), Jiri Vencovsky (Czech Republic),
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Merete Lund Hetland (Denmark), Tnu Peets (Estonia), Bruno Fautrel (France),
20 Putrik P, Sokka T, Ramiro S, et al. Impact of socioeconomic gradients within and
Khatuna Letsveridze (Georgia), Ulf Mller-Ladner (Germany), Prodromos Sidiropoulos
between countries on health of patients with rheumatoid arthritis (RA): Lessons
(Greece), Mrta Pntek (Hungary), Gerdur Grndal (Iceland) Fiona McGrehan
from QUEST RA. Best Pract Res Clin Rheumatol 2012;26:70520.
(Ireland), Seriolo Bruno (Italy), Togizbayev Galymzhan (Kazakhstan), Daina
21 Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efciency of
Andersone (Latvia), Irena Butrimiene (Lithuania), Marco Hirsch (Luxemburg), Snezana
guideline dissemination and implementation strategies. Health Technol Assess
Misevska-Percinkova (Macedonia), Karen Cassar (Malta), Elena Deseatnicova
2004;8:iiiiv, 172.
(Moldova), Dusan Mustur (Montenegro), Filip Raciborski (Poland), Viviana Tavares
22 van den Berg R, Stanislawska-Biernat E, van der Heijde DM. Comparison of
(Portugal), Florian Berghea (Romania), Ivan Shirinsky (Russia), Miodrag Veljkovic
recommendations for the use of anti-tumour necrosis factor therapy in ankylosing
(Serbia), Maria Kovarova (Slovakia), Matija Tomsic (Slovenia), Francisca Sivera
spondylitis in 23 countries worldwide. Rheumatology 2011;50:22707.
(Spain), Ingemar Petersson (Sweden), Axel Finckh (Switzerland), Shaydullo Sharipov
23 Fernandes V, de Assis TM, Queiroz CC, et al. Use of biological therapies in
(Tajikistan), Nevsun Inanc (Turkey), Tatyana Dumenko (Ukraine), Suzanne Verstappen
rheumatoid arthritis management: a comparison between the main worldwide and
(UK), Hojimurad Khudoberdiev (Uzbekistan) have contributed with corresponding
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country-specic data, provided additional insights and necessary clarications about
24 Initiative Arznei&Vernunft Vernnftiger Umgang mit Medikamenten in Rheumatoider
the national data and critically reviewed the interpretation of the results as well as
Arthritis, 2012.
the nal draft of the manuscript.
25 Erstattungskodex des sterreichischen Hauptverbandes.
Competing interests Polina Putrik was supported by High Potential Scholarship 26 Guidelines treatment with disease modifying drugs in RA/Consensus-statement for
awarded by Maastricht University. Sokka Tuulikki received grants from Abbott, B-cell modifying drugs/for T-cell modifying drugs National Austrian League of
Academy of Finland and Central Finland Health Care District; Soa Ramiro was Rheumatology, 2006 (DMARDs RA) 2008 (B-cells)/2009 (T-cells).
supported by the Fundao para a Cincia e Tecnologia (FCT) grant SFRH/BD/ 27 RIZIV (Rijksinstituut Ziekteverzekering), 2001 (updated in 2010).
68684/2010; Tore K Kvien has received honoraria and research support from 28 National guidelines for treatment of rheumatoid arthritis with biologic DMARDs,
Abbott, BMS, MSD/Schering-Plough, Pzer/Wyeth, Roche and UCB; Till Uhlig has Bulgarian Scientic Society in Rheumatology, 2008.
received honorary/support for travel from Abbott, BMS, MSD, Pzer and UCB; and 29 Recommendation for use of TNF blocking drugs in rheumatoid arthritis, Croatian
Annelies Boonen received project grants from Amgem, Abbott and MSD and Society for Rheumatology, 2007.
honoraria from UCB, Abbott and Pzer. 30 Curkovic B, Babic-Naglic D, Morovic-Vergles J, et al. [Proposal for biologic drugs
Provenance and peer review Not commissioned; externally peer reviewed. therapy in rheumatoid arthritis]. Reumatizam 2010;57:2935.
31 Odluka o utvrivanju Osnovne liste, lijekova Hrvatskog zavoda za zdravstveno
Correction notice This article has been corrected since it was published Online osiguranje, 2010.
First. The collaborators and contributors sections have been amended. 32 A modied version of NICE guidelines, Cyprus Society for Rheumatology &
Pharmaceutical Services of the Ministry of Health, 2007.
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Ann Rheum Dis 2014 73: 2010-2021 originally published online August
12, 2013
doi: 10.1136/annrheumdis-2013-203819
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