Discordant perspectives of rheumatologists and patients on COBRA combination therapy in rheumatoid arthritis

Rheumatology (Oxford). 2008 Oct;47(10):1571-6. doi: 10.1093/rheumatology/ken323. Epub 2008 Aug 18.


Objective: The COBRA therapy (combination therapy in early rheumatoid arthritis) has proven to be an effective treatment for early RA, but is rarely prescribed. A survey showed reluctance of Dutch reumatologists to apply COBRA therapy in early RA. The present qualitative study was carried out to further explore the reservation of Dutch rheumatologists towards prescribing COBRA therapy and include patients' view on (components of) COBRA therapy.

Methods: Two focus group discussions were undertaken for rheumatologists (n(1) = 8, n(2) = 7) and two for patients (n(1) = 4, n(2) = 8). In addition, in-depth interviews were conducted with 11 rheumatologists and 1 patient. These were taped and transcribed. Two independent researchers identified themes and these were discussed with three other researchers.

Results: Rheumatologists were positive concerning effectiveness of COBRA therapy, but highly concerned about their patients' possible negative reaction to the large amount of pills to be prescribed. In addition, rheumatologists perceived lack of time explaining and prescribing COBRA therapy and felt uncomfortable prescribing high doses of prednisolone. Patients were positive about an aggressive combination therapy such as COBRA, and they had no qualms taking many pills if this could improve their prognosis. Patients associated prednisolone with negative side-effects, but were also aware of the benefits and the need of prednisolone in rough times. A decrease in the amount of pills after intensive treatment was highly appreciated.

Conclusion: Rheumatologists and patients differed in opinion about the use of COBRA therapy. Rheumatologists were particularly concerned about their patients' reaction towards them prescribing such an aggressive and complex therapy, whereas patients, while aware of the side-effects, were most interested in suppressing illness symptoms and reducing future damage regardless of the amount of pills.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antirheumatic Agents / adverse effects
  • Antirheumatic Agents / therapeutic use*
  • Arthritis, Rheumatoid / drug therapy*
  • Attitude of Health Personnel*
  • Attitude to Health*
  • Drug Therapy, Combination
  • Female
  • Focus Groups
  • Humans
  • Male
  • Methotrexate / adverse effects
  • Methotrexate / therapeutic use
  • Netherlands
  • Practice Patterns, Physicians' / statistics & numerical data
  • Prednisolone / adverse effects
  • Prednisolone / therapeutic use
  • Sulfasalazine / adverse effects
  • Sulfasalazine / therapeutic use


  • Antirheumatic Agents
  • Sulfasalazine
  • Prednisolone
  • Methotrexate