Facilitating the Use of COBRA Combination Therapy in Early Rheumatoid Arthritis: A Pilot Implementation Study
Department of Rheumatology, EMGO Institute, and the Department of Epidemiology and Biostatistics, VU University Medical Center, 1081 HV Amsterdam, The Netherlands. The Journal of Rheumatology
(Impact Factor: 3.19).
07/2009; 36(7):1380-6. DOI: 10.3899/jrheum.081078
COBRA combination therapy is well known and has uncontested efficacy in the treatment of rheumatoid arthritis (RA). However, it is infrequently applied in Dutch clinical practice. Based on qualitative research on opinions of physicians and patients towards COBRA therapy, our study describes the development and pilot testing of an implementation package to facilitate prescription and use of COBRA therapy in early RA.
The implementation package was developed to address specific barriers towards prescription of COBRA therapy and comprised informational handouts (an information booklet and leaflet for patients), preprinted prescription orders, and background information on COBRA therapy for the rheumatologists. Twenty-two rheumatologists agreed to participate, including the arthritis nurse where available. Rheumatologists, nurses, and patients were asked to record their experience. All Dutch arthritis nurses were invited to an educational session on COBRA therapy.
Sixteen rheumatologists accompanied by 10 arthritis nurses used the material to prescribe COBRA therapy to a total of 27 patients. Rheumatologists and nurses both gave high marks to the supplied materials. Eighty-eight percent of rheumatologists reported that the material sped up the prescription process, and 65% indicated they would prescribe COBRA therapy more frequently if these materials were available routinely. Patients expressed great satisfaction with the information handouts, rating it 2.8 (standard deviation 0.5) on a scale of -3 (very negative) to +3 (very positive). Most patients (89%) planned to keep the information booklet as a reference and 70% used it as a tool to remember the correct intake of medication. The attitude and perceived capability of nurses towards the guidance of patients with RA receiving COBRA therapy was improved through a brief educational intervention.
Rheumatologists, patients, and arthritis nurses all highly appreciated the implementation package and indicated that its availability would increase uptake of COBRA therapy.
Available from: Nidhi Sofat
- "The main studies, which have informed practice, are discussed by Horton, Walsh, and Emery in Chapter 5. There are now data for combination conventional therapy   and biologic therapy commenced in early RA as being more effective in achieving rapid disease remission  . In Chapter 8, Thalayasingam and Isaacs discuss the relative merits of individual tumour necrosis factor alpha inhibitor (TNFi) therapies while Leandro and Becera-Fernandez discuss specific aspects of B-cell depletion therapy in Chapter 7. Another key question in the conventional DMARD and biologics era is to establish when it is safest for therapies to be stepped up or stepped down and which parameters should be used to decide on such changes. "
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Best practice & research. Clinical rheumatology 08/2011; 25(4):435-46. DOI:10.1016/j.berh.2011.10.011 · 2.60 Impact Factor
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ABSTRACT: This article provides a perspective on the immediate and follow-up results of the COBRA trial that compared the combination of step-down prednisolone, methotrexate and sulfasalazine with sulfasalazine monotherapy in early rheumatoid arthritis (RA). The combination provided immediate relief of symptoms and signs of RA, but the clinical benefit compared to monotherapy appeared mostly dependent on low-dose glucocorticoid therapy that was mandatorily discontinued after 28 weeks. Strong benefit was apparent in the slowing of joint damage progression, and this effect persisted for over 10 years despite uncontrolled therapy after the trial period. In the trial toxicity of COBRA was less than monotherapy, and long-term safety of the regimen was comparable to regimens that do not include glucocorticoids. COBRA was the first study to validate the 'reverse-pyramid' concept in RA, and helped to establish the idea of a window of opportunity where the prognosis of RA may be altered with early and intensive therapy. Subsequent studies have shown COBRA is feasible in practice, acceptable to patients, and has efficacy similar to the combination of TNF inhibition and high-dose methotrexate, at a fraction of the cost.
Clinical and experimental rheumatology 01/2011; 29(5 Suppl 68):S46-51. · 2.72 Impact Factor
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