At present, there are many different ways to treat rheumatoid arthritis (RA), raising questions about which approaches produce the best results in the real-world setting and which are the most cost effective. Among these approaches, COBRA (based on the Dutch acronym Combinatie therapie Bij Rheumatoide Arthritis) therapy is a well-known and thoroughly investigated combination therapy for the treatment of early RA. This combination consists of three disease-modifying antirheumatic drugs (DMARDs), including methotrexate, sulfasalazine, and an initial period with a high dose of prednisolone (60 mg/d tapered in six weeks to 7.5 mg/d). (See Figure 1, p. 23.) COBRA leads to faster suppression of disease activity and less joint damage in the long term compared with sulfasalazine monotherapy. Moreover, the COBRA combination is as effective as high-dose methotrexate in combination with infliximab and is cost effective compared with other antirheumatic therapies.1-5
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Explore This IssueJune 2010
Despite these features and its long-term benefits, COBRA therapy is not often prescribed in clinical practice, at least not by Dutch rheumatologists. We therefore asked, “Why not?” and performed studies to better understand the prescription pattern of COBRA and determine whether it can be changed. For our study, we sent a small questionnaire to every rheumatologist in the Netherlands to measure attitudes towards the combination therapy and the frequency of use.
From the responses, we learned that COBRA therapy was regarded as effective and safe but also rather complicated to administer. Remarkably, although the overall attitude of rheumatologists towards COBRA therapy was slightly positive, the majority of responding rheumatologists did not intend to prescribe COBRA therapy in the near future. These results gave us the first indication of the contradictory feelings surrounding COBRA therapy.6
To study this discrepancy further, we organized focus group discussions with both patients and rheumatologists (in separate groups). In these groups, rheumatologists indicated that they were positive about the effectiveness of COBRA therapy but concerned about their patients’ possible negative reaction to the large number of pills to be taken. Doctors feared the reaction of patients, including a sense of failure toward their providers and that the therapy prescribed is considered disagreeable. In addition, rheumatologists felt that they lacked the time to explain and prescribe COBRA therapy and felt uncomfortable prescribing high doses of prednisolone.7
On the other hand, patients who joined the focus groups (mostly late RA patients with a broad experience of treatment regimens, including COBRA) were positive about an aggressive combination therapy such as COBRA therapy. Importantly, patients said that they had no qualms taking many pills if this would provide immediate relief of their symptoms or might improve their prognosis. Patients associated prednisolone with negative side effects (especially their effects on appearance), but they were also aware of its benefits and the need to take prednisolone in rough times of active arthritis. Patients stated that they based their opinions on their own experience at the start of the disease and concluded that taking many pills felt much better than the pain and limitations they were facing with the disease. A decrease in the number of pills after a period of intensive treatment was highly appreciated.