This document discusses decision making for arthritis patients, specifically regarding medication choices. It notes that while small medication decisions like exercises and topical treatments are made regularly, bigger decisions around surgery and disease-modifying drugs are more complex. For osteoarthritis, over 1 million GP consultations and 17 million prescriptions are written annually for anti-inflammatory drugs and topical treatments, costing over £400 million. While most patients prefer anti-inflammatory drugs to paracetamol, studies suggest some may prefer less effective but safer options. The best decisions are made jointly with clinicians and consider benefits, risks, and alternatives. Perceptions of risk and benefit can vary depending on factors like condition severity and past experiences. With open communication, patients

1. Supporting
Informed Choices
Martin Underwood

2. Talking about Arthur

3. Decision making in arthritis?
• Decision making is complex
• and poorly understood
• Big Decisions
• Surgery
• Disease Modifying Anti-Rheumatic Drugs
• ‘Small’ Decisions
• Exercises
• Appliances
• Drugs

4. Drugs for osteoarthritis
• Small everyday decision in GP’s surgery
& the pharmacy
• >1,000,000 GP consultations per year for OA
• >17,000,000 prescriptions for
anti-inflammatory drugs
• >4,000,000 topical preparations

5. Big consequences
• Consultations, prescriptions, and treating
side effects cost >£400,000,000 PA.
• Drug side effects
• Gastric Bleeding
• Raised Blood Pressure
• Cardiovascular Disease
• Risk for an individual is not clear
• Comparative risks are different for different
drugs

6. Preferences
• Most people with arthritis prefer
anti-inflammatory drugs to paracetamol
• More effective?
• Studies suggest that many people might
prefer a less effective but safer medication
• Many people prefer topical preparations to
oral medications

7. Decision making
• More benefit if made jointly with clinician
that they trust
• Take into account, benefits, risks and
availability of alternative treatments
• Information quality?
• Risk evaluation affected by perceived
severity of condition

8. Where does patient
information come from?
• Past experience
• Theirs and that of friends/relatives
• Tradition
• Medical advisors
• Written material (traditional & modern)
• Folk models of illness

9. Do patients make the correct
choices?
• Effectiveness relatively easy
• Adverse events harder
• Poor data
• Most people not affected
• Topical or Oral Ibuprofen study (TOIB)
• People who chose oral medication had fewer
side effects than those randomised to oral
medication

10. Perception of risk and benefit
High risk
•(Oral) Beneficial High tolerance to adverse
effect effects
Little effect
Low risk Low tolerance to adverse
•(Topical) effects

11. How did they decide
GP knows best
Uncritical acceptance of various information
sources
Nature of pain - -constant /transient
– Regular or as required
Trade off between pain relief, side effects
and, improved function.

12. Types of pain and medication use
Regular NSAID use
Constant pain
More pain more Regular NSAID use with reserve
medication
As required
Transient pain
Pre-emptive

13. A balanced decision making
process?

14. Factors influencing patient preferences for
topical or oral ibuprofen
Carnes, D. et al. BMJ 2008;336:142-145
Copyright ©2008 BMJ Publishing Group Ltd.

15. On the other hand
Normalisation of
– arthritis pain
• not aspiring to improvement
– minor side effects
• possible increased risk of serious side effects

16. Supporting
Informed Choices

17. Conclusions
• Most patients are pretty good at making
informed choices
• Shared informed decision making key to
getting right balance of risks/benefits
• Practitioners - data on risks and benefits
• Patients – relative values of risk and benefits