Tapering or Discontinuation of Methotrexate in Stable Disease- Opinions From Rheumatoid Arthritis Patients and Rheumatology Providers at Two Academic Healthcare Centers

Tapering or Discontinuation of Methotrexate in Stable Disease- Opinions From Rheumatoid Arthritis Patients and Rheumatology Providers at Two Academic Healthcare Centers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tapering or Discontinuation of Methotrexate in Stable Disease- Opinions From Rheumatoid Arthritis Patients and Rheumatology Providers at Two Academic Healthcare Centers Peri Newman, Tarun Sharma, Rayford June, Nicole Wilson, Glennys Smith, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9142998/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Current treatment guidelines for rheumatoid arthritis (RA) favor discontinuation of methotrexate (MTX) over biologic (b) DMARDs. To assess acceptability of this approach, we conducted a cross-sectional study evaluating the perspectives of patients and providers on MTX tapering at one urban and one rural health care center. Methods Rheumatologists and patients were surveyed at the two health centers, one in an urban location and one with a predominantly rural service area. Patient surveys collected demographics, history of MTX use, and views on tapering. Provider surveys included questions about years of rheumatology practice and strategies being employed for tapering. Data were analyzed using chi-square and Wilcoxon rank sum tests in both questionnaire groups. Results Surveys were collected over a 3 year period, from January 2020 through the end of 2022. Of the 143 patient respondents, 78% female and 86% were White. Median duration of RA was 12 years. Tapering trials of MTX were more frequent at the urban facility (p = 0.02) and were more often considered in males with stable disease activity (p = 0.005, and p = 0.042,) and those with longer disease duration. Tapering concerns were greater for female patients on MTX for at least 8 years (p = 0.046). Surveys collected from 16 urban providers and 8 rural providers showed that those with less than 15 years of experience were more likely to consider tapering if patients were concurrently on other treatments favorable for tapering (p = 0.019) and were likely to consider patient preferences against tapering (p = 0.004). None of the other differences between the two centers were significant. Conclusion We identified factors influencing tapering decisions for both patients and rheumatology providers, including age, race, sex, RA duration and provider’s years of experience. Consideration of these will facilitate designing acceptable future approaches to MTX tapering in patients with stable RA. rheumatoid arthritis methotrexate medication tapering patient preference provider preference Background Rheumatoid arthritis (RA), a chronic autoimmune disease, affects 0.25–1% of the global population and leads to progressive joint damage and disability, particularly in adults over the age of 40. 1 Prompt initiation of disease-modifying, anti-rheumatic drug (DMARD) therapy within three months of diagnosis decreases structural damage and prevents disease progression. 2 The 2021 American College of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis recommend initial treatment with methotrexate (MTX) monotherapy for DMARD-naïve RA patients with moderate to severe disease activity. 3 However, long-term immunosuppression and MTX use can lead to severe adverse reactions including serious infection and hepatotoxicity, especially in older patients with comorbidities. 4 , 5 Therefore, once RA patients achieve low disease activity or remission, MTX tapering should be considered. Successful drug tapering is achieved through shared decision making between patients and practitioners. Here, we surveyed RA patients and providers to determine factors influencing MTX tapering decisions. Recent data from the ARCTIC REWIND trial suggest the possibility of achieving flare-free tapering of conventional synthetic DMARDs (csDMARDs) such as MTX in > 50% patients. 6 While exploring biological predictors of successful tapering is important, it is equally important to understand patient and provider thoughts and preferences to help guide the tapering process. 7 A previous interview-based study found RA patients’ and rheumatologists’ perspectives on tapering DMARDs vary and evolve over time, with rheumatologists generally open to tapering (not stopping) only when requested by their patients in some cases. 8 Another study surveyed patients with stable RA and rheumatology providers and found patients were more likely to consider tapering bDMARDs and targeted synthetic (ts) DMARDs, especially when not being treated with concomitant csDMARDs or glucocorticoids. 9 However, there is currently a lack of literature on patient and provider preferences within different demographics, including time in practice and duration of disease, that affect decisions to taper DMARDs. In this study, we surveyed RA patients and providers practicing at two tertiary care academic centers to determine variables influencing MTX tapering decisions. Our study utilized differences in the two care centers to determine patient characteristics associated with MTX tapering decisions over a larger geographic population. We also evaluated the impact of the geographic distribution of RA patients (urban vs. rural setting) on tapering concerns and consideration. Methods Patients and providers from Penn State Health (PSH) and Allegheny Health Network (AHN) were surveyed to analyze perspectives of MTX tapering between 01/01/2020 and 12/31/2022. Using electronic medical records from PSH and AHN, we identified patients diagnosed with RA via ICD9 or ICD-10 codes. We included RA patients ≥ 18 years old on a stable MTX dose for ≥ 6 months and attended an outpatient rheumatology clinic appointment between 1/1/2020 and 12/31/2022 at PSH or AHN. Exclusion criteria included absence of electronic health records and inability to complete a questionnaire because of cognitive, language, or literacy barriers. PSH patients represented a largely rural patient population, and AHN patients represented an urban population. Rheumatology providers practicing at PSH and AHN, including faculty, fellow trainees, and advanced practice providers were also included. Participation was voluntary. Patients who met criteria and were seen by their provider were asked at the visit to complete the survey either electronically online into REDCap or in person at the visit. Providers were invited via email with a survey link to complete the survey electronically online into REDCap. The surveys were developed for this study and are included in the supplementary files ( Supplementary File-1 Patient Methotrexate Tapering Survey and Supplementary File-2 Provider Methotrexate Taper Survey ). Patient surveys collected respondents’ age, gender, race, ethnicity, RA disease history, self-assessed RA status (0 = very well, 10 = poor), duration of RA diagnosis and MTX use in years, and views on MTX tapering. Provider surveys asked number of years in practice as a rheumatologist ( 15 years), opinions on tapering patients with stable RA, and preferred tapering strategies. Providers at different experience levels were also asked to rate the importance of variables categorized as being in favor of or against MTX tapering. This study was approved by the Institutional Review Boards of the Pennsylvania State University and the Allegheny Health Network and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki. Data were collected in one REDCap database. Patient data were stratified by healthcare network location, self-identified gender, self-identified race (White or non-White), and self-identified ethnicity. Descriptive statistics were completed for age, duration of MTX use, and RA duration. Provider data were stratified by site and years in practice. Chi-square analysis compared survey responses between AHN and PSH patients and between male and female patients. Two-sample t-tests and Wilcoxon rank sum tests compared patient age, years with RA, and years on MTX between patients who responded positively or negatively to survey questions. Factor importance ratings were compared based on the number of years providers have practiced rheumatology using Wilcoxon rank sum tests. SAS (SAS Institute, Cary, NC) was used for all analyses, and statistical significance was set at p < 0.05. Results Patient perspectives A total of 143 patients completed the survey (73 AHN; 70 PSH). The patient population was 78% female (n = 112) and 85% White (n = 121). Mean RA duration was 16.06 years (± 13.29 standard deviation [SD]). Self-assessed RA status (0 = very well, and 10 = poor) was significantly better in White patients (mean score = 5.06) than in non-White patients (mean score = 3.41; p = 0.007). AHN had significantly more non-White patients than PSH ( p = 0.002, Table 1 ). PSH patients were older (≥ 65 old) than AHN patients ( p = 0.013). Self-assessed RA status did not differ by site (p = 0.311) Table 1 Comparison of self-reported demographics from 73 patients at the urban Allegheny Health Network (AHN) and 70 patients at the rural Penn State Health (PSH) sites† Gender Urban AHN (N = 73) n (%) Rural PSH (N = 70) n (%) p -value Male 18 (24.7) 13 (18.6) 0.377 Female 55 (75.3) 57 (81.4) Race White 55 (77.5) 66 (95.7) 0.002* Non-White 16 (22.5) 3 (4.3) Ethnicity Hispanic 0 3 (4.3) 0.113 Non-Hispanic 72 (100) 66 (96.7) Age Younger than 65 42 (61.8) 28 (40.6) 0.013* At least 65 26 (38.2) 41 (59.4) * statistically significant † total values do not equal 100% due to separate site enrollment MTX tapering consideration and patient concerns significantly differed by patient gender, study site, duration of RA, and duration of MTX (Table 2 ). When comparing tapering between study sites, more patients at AHN underwent MTX tapering than at PSH ( p = 0.02). Across both AHN and PSH, male patients (n = 13 [41.9%]) underwent MTX tapering more frequently than female patients (n = 20 [17.9%], p = 0.005). MTX tapering was also considered more often by male patients (n = 29 [96.7%]) than female patients (n = 85 [81%], p = 0.042) and by patients diagnosed with RA > 21 years ( p = 0.01). Patients treated with MTX ≥ 8 years were more likely to have previously tapered or discontinued MTX (p = 0.044) but also reported greater concern about risks of reducing or stopping the drug (p = 0.004), particularly related to flares (p = 0.002) and worsening disease (p = 0.001). Female patients were also more concerned about risks of flares than male patients ( p = 0.046). Table 2 Survey results to six questions asked of patients as categorized by institute, sex, age, and rheumatoid arthritis (RA) history. 1. Consideration of MTX tapering if RA was well-controlled Yes n (%) p -value* Yes (Mean ± SD) No (Mean ± SD) p -value** Institute Penn State Health (rural) 55 (79.7) 0.121 Allegheny Health Network (urban) 59 (89.4) Sex Male 29 (96.7) 0.042 Female 85 (81.0) Age (years) 62.2 ± 13.5 63.8 ± 12.7 0.870 Years on MTX 9.8 ± 9.2 10.1 ± 7.1 0.481 Years with RA 16.3 ± 13.2 13.3 ± 10.6 0.607 2.Tapered off MTX in clinical practice due to stable disease activity Institute Penn State Health (rural) 11 (15.1) 0.020 Allegheny Health Network (urban) 22 (31.4) Sex Male 13 (41.9) 0.005 Female 20 (17.9) Age (years) 63.7 ± 11.6 62.3 ± 13.7 0.615 Years on MTX 11.7 ± 7.2 9.5 ± 9.8 0.015 Years with RA 16.5 ± 11.5 15.9 ± 13.8 0.385 3. Concerned overall with reducing or stopping MTX Institute Penn State Health (rural) 27 (39.1) 0.675 Allegheny Health Network (urban) 29 (42.7) Sex Male 10 (32.3) 0.267 Female 46 (43.4) Age (years) 62.3 ± 13.1 62.2 ± 13.5 0.963 Years on MTX 11.5 ± 9.3 8.4 ± 8.4 0.035 Years with RA 17.9 ± 13.6 14.1 ± 12.1 0.061 4. Concerned about risk of flare when reducing or stopping MTX Institute Penn State Health (rural) 21 (30.0) 0.871 Allegheny Health Network (urban) 21 (28.8) Sex Male 6 (19.4) 0.167 Female 36 (32.1) Age (years) 60.03 ± 13.4 63.7 ± 13.1 0.136 Years on MTX 12.2 ± 9.3 9.0 ± 9.2 0.029 Years with RA 19.2 ± 14.1 14.7 ± 12.8 0.030 5. Concerned about worsening when reducing or stopping MTX Institute Penn State Health (rural) 15 (21.4) 0.446 Allegheny Health Network (urban) 12 (16.4) Sex Male 2 (6.5) 0.046 Female 25 (22.3) Age (years) 60.9 ± 14.6 63.1 ± 12.9 0.441 Years on MTX 13.1 ± 9.1 9.2 ± 8.9 0.034 Years with RA 19.9 ± 14.7 15.2 ± 12.9 0.046 6. Skipped or forgotten to take MTX Institute Penn State Health (rural) 29 (41.4) 0.376 Allegheny Health Network (urban) 25 (34.3) Sex Male 8 (25.8) 0.121 Female 46 (41.1) Age (years) 57.1 ± 14.3 66.1 ± 11.4 < 0.001 Years on MTX 10.6 ± 8.3 9.6 ± 9.9 0.208 Years with RA 16.9 ± 12.2 15.6 ± 14.0 0.229 Note : SD =standard deviation * p -value from chi-square test ** p -value from two-sample t-test (age) or Wilcoxon rank sum test (years on MTX, years with RA) Provider perspectives Twenty-four providers (16 AHN; 8 PSH) completed the survey with a100% response rate. Ten providers (42%) had been practicing rheumatology for ≥ 15 years (Table 3 ). Variables in favor of or against tapering were ranked by importance, from 1 (very important) to 5 (least important). When comparing rankings between AHN and PSH providers, we found no significant differences (not shown). Comparing the group of providers with < 15 years of experience (n = 14) to those with greater experience, significant differences were found for two variables—concurrent DMARD therapy and patient preference (Table 3 ). Of the five variables in favor of tapering, only concurrent DMARD was considered significantly more important by providers who had been practicing for longer ( p = 0.019). The importance of achieving remission, risks of long-term medication use, and patient noncompliance with monitoring did not significantly differ between providers. For the six variables against tapering, providers with more experience viewed patient preference as significantly less important than those with less experience ( p = 0.004). Importance ratings for radiographic progression, multiple treatment failures, and challenges regaining remission after flare did not differ significantly. Table 3 Comparison of the mean importance ratings of the factors influencing providers’ tapering decision between with < 15 years in practice (YIP) and those with ≥ 15 YIP. < 15 YIP (N = 14) ≥ 15 YIP (N = 10) Mean Importance Rating* p -value Variables in favor of tapering Stable remission 1.36 1.00 0.246 Risks of long-term MTX 2.57 3.10 0.319 Noncompliance with monitoring 1.93 2.00 0.685 Patient preference 2.21 1.90 0.547 On concurrent DMARD 1.93 1.10 0.019 Variables against tapering Risk of flare 1.29 1.30 0.756 Patient preference 1.65 2.60 0.004 Difficulty of recapturing remission 2.14 2.10 0.713 Failed multiple previous therapies 1.36 1.60 0.608 Risk of radiographic progression 2.29 1.06 0.166 MTX useful to reduce immunogenicity or boost effect of bDMARD 2.00 2.50 0.209 Note : bDMARD: biologic disease-modifying, anti-rheumatic drugs; DMARD: disease-modifying, anti-rheumatic drugs *The importance rating scale ranged from 1 very important to 5 being least important. The mean value of the responses was calculated and presented here. Discussion In this study, surveys of RA patients and providers in two academic centers about MTX tapering found MTX tapering was more often attempted in male patients, patients treated at AHN, and patients with stable disease activity, long-term disease (> 6 years), and > 8 years of MTX use. Female patients with well-controlled RA were less likely to consider tapering and more concerned about the associated risks than their male counterparts. Greater concern of worsening disease and risk of flare was also observed in patients with > 8 years of MTX use. Furthermore, older patients were more likely to adhere to prescribed regimens. We also found rheumatology providers with < 15 years of experience were more likely to suggest MTX tapering to patients on concurrent DMARD therapy and considered patient preference less important than providers with more experience. Previous studies on RA patient preferences report patients and providers to have concerns regarding increased risk of flares during DMARD tapering. For example, one study found patients were receptive to recommendations of medication dose reduction but expressed concerns about flare risks with tapering and the need for timely provider communication and a clear plan if tapering was unsuccessful. 10 Another study investigating patient and rheumatologist perspectives on tapering DMARDs in RA found while acknowledging the potential benefits of tapering such as reducing side effects, both the patients and physicians interviewed in the study were cautious, noting lack of evidence. 8 Fear of flare and time it would take to return to a stable low activity state remains an obstacle for patients and providers in DMARD tapering decisions. 8 In our study, RA patients that had been treated with MTX > 8 years were more likely to be concerned about the risk of flares and worsening disease. Additionally, male patients were more likely to consider MTX tapering as female patients were more concerned about the risks associated with tapering. The AHN team has previously reported on the risk of flare in RA patients who had well-controlled disease. 10 In this real-world cohort comparing tapering of different medications, flare rates were lowest while tapering in those on conventional synthetic DMARDs, such as MTX, compared to bDMARDs. 11 The official guidelines for RA treatment recommend gradual discontinuation of MTX under certain conditions and with little evidence. 3 Rheumatologists may be more likely to consider tapering or discontinuing DMARD therapy in their stable patients, but there are currently no strong guides for the best timing or strategies for tapering, and treatment is individualized to each patient and circumstance. This lack of strong guidelines leads to variation in provider preferences and decision making when considering MTX tapering. We found few differences in the importance ratings of variables influencing MTX tapering decisions between providers at AHN and PSH and those with different experience levels. However, providers with less experience (< 15 years practicing rheumatology) were more likely to suggest MTX tapering to patients on concurrent DMARD therapy and considered patient preference less important than providers with more experience. This study has several strengths and limitations. Strengths include the inclusion of patients in both rural and urban settings for a broader view of MTX tapering in patients from different geographic locations. Providers with different backgrounds/education (advanced practice providers vs. medical physicians) and years in practice were included. Pre-determined standardized responses were used in the surveys to make data collection and interpretation more uniform. Notably, data collection occurred during the COVID-19 pandemic for which heightened awareness of the effect of medications on disease and health could have raised patient awareness about tapering issues. Limitations include a lack of patient diversity with most patient respondents being White, selection bias in the clinics chosen to participate in the survey, and recall bias on behalf of the patient in choosing how to answer the questions about their years on MTX and years of diagnosis. Finally, since we did not collect the number of total patients asked to complete the survey vs. the number collected; an accurate survey response rate could not be determined. Conclusions Patients generally do not wish to take more medication than needed, and patient preferences on medication tapering or discontinuation in stable disease are important for shared decision making. Some of the results in our study are not unexpected, but pursuing guided strategies that are likely to succeed in medication dose reduction will require further study. Studies including patient and provider preferences on taper, especially studies such as this that build upon prior studies and validate prior thoughts and findings are needed. Furthermore, these results strongly suggest shared decision making among patients and providers to taper or discontinue medications including MTX will be critical to successful outcomes and provide a good starting point for future designed patient care standardized tapering guidelines. Abbreviations RA Rheumatoid Arthritis DMARD Disease Modifying Anti Rheumatic Drug MTX Methotrexate csDMARD conventional synthetic Disease Modifying Anti Rheumatic Drug bDMARD biologic Disease Modifying Anti Rheumatic Drug tsDMARD targeted synthetic Disease Modifying Anti Rheumatic Drug PSH Penn State Health AHN Allegheny Health Network Declarations Ethics approval and consent to participate: This study was approved by the Institutional Review Boards of the Pennsylvania State University and the Allegheny Health Network and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki. Consent for publication: Not applicable Competing Interests : The author(s) declare(s) that they have no competing interests. Funding This project was supported by funding from Highmark Health and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1 TR002014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH and Highmark Health Author Contribution P.N. and S. B and N.O. and R. J. wrote main manuscript, contributed to study design, IRB approval and patient recruitment at Penn State HealthE.L and V. R. and G. S. contributed statistical support, study design and data entryP.N contributed to data entryT. S and N. W. and G. S. contributed to Study design, and patient recruitment and data entry at Allegheny HealthP. N. contributed to table and figure development and preparationAll authors reviewed manuscript and approved the final manuscript Acknowledgement The authors thank Sarah Carey, MS, and Jacalyn Newman, PhD, of Allegheny Health Network’s Health System Publication Support Office (HSPSO) for their assistance in editing and formatting the manuscript. The HSPSO is funded by Highmark Health (Pittsburgh, PA, United States of America), and all work was done in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3). Data Availability Data have restricted access due to inclusion of protected health information but are available upon request to the corresponding author for an anonymized dataset. References Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001;358(9285):903–11. Di Matteo A, Bathon JM, Emery P. Rheumatoid arthritis. Lancet. 2023;402(10416):2019–33. Fraenkel L, Bathon JM, England BR, et al. 2021 American college of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021;73(7):924–39. Muanda FT, Blake PG, Weir MA, et al. Low-dose methotrexate and serious adverse events among older adults with chronic kidney disease. JAMA Netw Open. 2023;6(11):e2345132. Hanoodi M, Mittal M, Methotrexate. 2025. In: StatPearls [Internet] [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556114/ Kjorholt KE, Sundlisaeter NP, Aga AB, et al. Effects of tapering conventional synthetic disease-modifying antirheumatic drugs to drug-free remission versus stable treatment in rheumatoid arthritis (arctic rewind): 3-year results from an open-label, randomised controlled, non-inferiority trial. Lancet Rheumatol. 2024;6(5):e268–78. Sharma T, Banks S. Medication tapering in stable rheumatoid arthritis: Where do we stand and what work needs to be done? Rheumatology (Oxford). 2023;62(Suppl4):iv1–2. Hazlewood GS, Loyola-Sanchez A, Bykerk V, et al. Patient and rheumatologist perspectives on tapering dmards in rheumatoid arthritis: A qualitative study. Rheumatology (Oxford). 2022;61(2):606–16. Wiemer N, Webster P, Attur M, et al. Patient perspectives on tapering biologic or targeted synthetic therapy in well-controlled rheumatoid arthritis and comparison with providers' perspectives. Rheumatology (Oxford). 2023;62(Suppl4):iv3–7. Hsiao B, Fraenkel L. Patient preferences for rheumatoid arthritis treatment. Curr Opin Rheumatol. 2019;31(3):256–63. Tageldin M, Wilson N, Yin Y, Sharma TS. A real-world 2-year prospective study of medication tapering in patients with well-controlled rheumatoid arthritis within the rheumatoid arthritis medication tapering (rheumtap) cohort. Rheumatology (Oxford). 2023;62(Suppl4):iv8–13. Additional Declarations No competing interests reported. Supplementary Files patientsurvey.pdf ProviderMethotrexateTaperSurve.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 15 May, 2026 Reviews received at journal 14 May, 2026 Reviewers agreed at journal 14 May, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 04 Apr, 2026 Reviewers invited by journal 31 Mar, 2026 Editor assigned by journal 31 Mar, 2026 Editor invited by journal 30 Mar, 2026 Submission checks completed at journal 29 Mar, 2026 First submitted to journal 29 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9142998","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617708288,"identity":"edbe820c-4744-43ef-95db-48b29cb72575","order_by":0,"name":"Peri Newman","email":"","orcid":"","institution":"Penn State Milton S. 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Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Lehman","suffix":""},{"id":617708299,"identity":"3cdf53a5-1c63-4913-b06d-25e3ede856a8","order_by":6,"name":"Vandana Rai","email":"","orcid":"","institution":"Allegheny Health Network","correspondingAuthor":false,"prefix":"","firstName":"Vandana","middleName":"","lastName":"Rai","suffix":""},{"id":617708304,"identity":"fbc87719-2124-40d2-9d92-c26dc15a7334","order_by":7,"name":"Nancy Olsen","email":"","orcid":"","institution":"Penn State Milton S. Hershey Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"","lastName":"Olsen","suffix":""},{"id":617708306,"identity":"1a830811-b6be-419f-8e1a-0c671b3b1fe9","order_by":8,"name":"Sharon Banks","email":"data:image/png;base64,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","orcid":"","institution":"Penn State Milton S. Hershey Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Banks","suffix":""}],"badges":[],"createdAt":"2026-03-17 02:24:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9142998/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9142998/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106240101,"identity":"1a852b3d-63d0-404f-b642-672b60b94a89","added_by":"auto","created_at":"2026-04-06 14:42:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1007732,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9142998/v1/34d62e14-51e7-43a5-85e6-580fb7b7fc62.pdf"},{"id":106240040,"identity":"e2b792c9-387d-4dd4-bea8-030c797cbeee","added_by":"auto","created_at":"2026-04-06 14:42:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":285027,"visible":true,"origin":"","legend":"","description":"","filename":"patientsurvey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9142998/v1/a36f0f275224c39b807f65e9.pdf"},{"id":106239954,"identity":"dad340d4-0839-4da0-8530-c89d4f1f8ea8","added_by":"auto","created_at":"2026-04-06 14:42:21","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":43642,"visible":true,"origin":"","legend":"","description":"","filename":"ProviderMethotrexateTaperSurve.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9142998/v1/8431430c9867a2081e042aa2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTapering or Discontinuation of Methotrexate in Stable Disease- Opinions From Rheumatoid Arthritis Patients and Rheumatology Providers at Two Academic Healthcare Centers\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eRheumatoid arthritis (RA), a chronic autoimmune disease, affects 0.25\u0026ndash;1% of the global population and leads to progressive joint damage and disability, particularly in adults over the age of 40.\u003csup\u003e1\u003c/sup\u003e Prompt initiation of disease-modifying, anti-rheumatic drug (DMARD) therapy within three months of diagnosis decreases structural damage and prevents disease progression.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The 2021 American College of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis recommend initial treatment with methotrexate (MTX) monotherapy for DMARD-na\u0026iuml;ve RA patients with moderate to severe disease activity.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e However, long-term immunosuppression and MTX use can lead to severe adverse reactions including serious infection and hepatotoxicity, especially in older patients with comorbidities.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Therefore, once RA patients achieve low disease activity or remission, MTX tapering should be considered. Successful drug tapering is achieved through shared decision making between patients and practitioners. Here, we surveyed RA patients and providers to determine factors influencing MTX tapering decisions.\u003c/p\u003e \u003cp\u003eRecent data from the ARCTIC REWIND trial suggest the possibility of achieving flare-free tapering of conventional synthetic DMARDs (csDMARDs) such as MTX in \u0026gt;\u0026thinsp;50% patients.\u003csup\u003e6\u003c/sup\u003e While exploring biological predictors of successful tapering is important, it is equally important to understand patient and provider thoughts and preferences to help guide the tapering process.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e A previous interview-based study found RA patients\u0026rsquo; and rheumatologists\u0026rsquo; perspectives on tapering DMARDs vary and evolve over time, with rheumatologists generally open to tapering (not stopping) only when requested by their patients in some cases.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Another study surveyed patients with stable RA and rheumatology providers and found patients were more likely to consider tapering bDMARDs and targeted synthetic (ts) DMARDs, especially when not being treated with concomitant csDMARDs or glucocorticoids.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, there is currently a lack of literature on patient and provider preferences within different demographics, including time in practice and duration of disease, that affect decisions to taper DMARDs.\u003c/p\u003e \u003cp\u003eIn this study, we surveyed RA patients and providers practicing at two tertiary care academic centers to determine variables influencing MTX tapering decisions. Our study utilized differences in the two care centers to determine patient characteristics associated with MTX tapering decisions over a larger geographic population. We also evaluated the impact of the geographic distribution of RA patients (urban vs. rural setting) on tapering concerns and consideration.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePatients and providers from Penn State Health (PSH) and Allegheny Health Network (AHN) were surveyed to analyze perspectives of MTX tapering between 01/01/2020 and 12/31/2022. Using electronic medical records from PSH and AHN, we identified patients diagnosed with RA via ICD9 or ICD-10 codes. We included RA patients\u0026thinsp;\u0026ge;\u0026thinsp;18 years old on a stable MTX dose for \u0026ge;\u0026thinsp;6 months and attended an outpatient rheumatology clinic appointment between 1/1/2020 and 12/31/2022 at PSH or AHN. Exclusion criteria included absence of electronic health records and inability to complete a questionnaire because of cognitive, language, or literacy barriers. PSH patients represented a largely rural patient population, and AHN patients represented an urban population. Rheumatology providers practicing at PSH and AHN, including faculty, fellow trainees, and advanced practice providers were also included. Participation was voluntary.\u003c/p\u003e \u003cp\u003ePatients who met criteria and were seen by their provider were asked at the visit to complete the survey either electronically online into REDCap or in person at the visit. Providers were invited via email with a survey link to complete the survey electronically online into REDCap. The surveys were developed for this study and are included in the supplementary files (\u003cb\u003eSupplementary File-1 Patient Methotrexate Tapering Survey and Supplementary File-2 Provider Methotrexate Taper Survey\u003c/b\u003e). Patient surveys collected respondents\u0026rsquo; age, gender, race, ethnicity, RA disease history, self-assessed RA status (0\u0026thinsp;=\u0026thinsp;very well, 10\u0026thinsp;=\u0026thinsp;poor), duration of RA diagnosis and MTX use in years, and views on MTX tapering. Provider surveys asked number of years in practice as a rheumatologist (\u0026lt;\u0026thinsp;5 years, 5\u0026ndash;15 years, and \u0026gt;\u0026thinsp;15 years), opinions on tapering patients with stable RA, and preferred tapering strategies. Providers at different experience levels were also asked to rate the importance of variables categorized as being in favor of or against MTX tapering.\u003c/p\u003e \u003cp\u003e This study was approved by the Institutional Review Boards of the Pennsylvania State University and the Allegheny Health Network and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eData were collected in one REDCap database. Patient data were stratified by healthcare network location, self-identified gender, self-identified race (White or non-White), and self-identified ethnicity. Descriptive statistics were completed for age, duration of MTX use, and RA duration. Provider data were stratified by site and years in practice.\u003c/p\u003e \u003cp\u003eChi-square analysis compared survey responses between AHN and PSH patients and between male and female patients. Two-sample t-tests and Wilcoxon rank sum tests compared patient age, years with RA, and years on MTX between patients who responded positively or negatively to survey questions. Factor importance ratings were compared based on the number of years providers have practiced rheumatology using Wilcoxon rank sum tests. SAS (SAS Institute, Cary, NC) was used for all analyses, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient perspectives\u003c/h2\u003e \u003cp\u003eA total of 143 patients completed the survey (73 AHN; 70 PSH). The patient population was 78% female (n\u0026thinsp;=\u0026thinsp;112) and 85% White (n\u0026thinsp;=\u0026thinsp;121). Mean RA duration was 16.06 years (\u0026plusmn;\u0026thinsp;13.29 standard deviation [SD]). Self-assessed RA status (0\u0026thinsp;=\u0026thinsp;very well, and 10\u0026thinsp;=\u0026thinsp;poor) was significantly better in White patients (mean score\u0026thinsp;=\u0026thinsp;5.06) than in non-White patients (mean score\u0026thinsp;=\u0026thinsp;3.41; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). AHN had significantly more non-White patients than PSH (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). PSH patients were older (\u0026ge;\u0026thinsp;65 old) than AHN patients (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013). Self-assessed RA status did not differ by site (p\u0026thinsp;=\u0026thinsp;0.311)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of self-reported demographics from 73 patients at the urban Allegheny Health Network (AHN) and 70 patients at the rural Penn State Health (PSH) sites\u0026dagger;\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban AHN (N\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural PSH (N\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (75.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (81.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (77.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (95.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66 (96.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYounger than 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.013*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least 65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (59.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger; total values do not equal 100% due to separate site enrollment\u003c/p\u003e \u003cp\u003eMTX tapering consideration and patient concerns significantly differed by patient gender, study site, duration of RA, and duration of MTX (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When comparing tapering between study sites, more patients at AHN underwent MTX tapering than at PSH (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). Across both AHN and PSH, male patients (n\u0026thinsp;=\u0026thinsp;13 [41.9%]) underwent MTX tapering more frequently than female patients (n\u0026thinsp;=\u0026thinsp;20 [17.9%], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). MTX tapering was also considered more often by male patients (n\u0026thinsp;=\u0026thinsp;29 [96.7%]) than female patients (n\u0026thinsp;=\u0026thinsp;85 [81%], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.042) and by patients diagnosed with RA\u0026thinsp;\u0026gt;\u0026thinsp;21 years (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). Patients treated with MTX\u0026thinsp;\u0026ge;\u0026thinsp;8 years were more likely to have previously tapered or discontinued MTX (p\u0026thinsp;=\u0026thinsp;0.044) but also reported greater concern about risks of reducing or stopping the drug (p\u0026thinsp;=\u0026thinsp;0.004), particularly related to flares (p\u0026thinsp;=\u0026thinsp;0.002) and worsening disease (p\u0026thinsp;=\u0026thinsp;0.001). Female patients were also more concerned about risks of flares than male patients (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvey results to six questions asked of patients as categorized by institute, sex, age, and rheumatoid arthritis (RA) history.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1. Consideration of MTX tapering if RA was well-controlled\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes \u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (89.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e63.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.Tapered off MTX in clinical practice due to stable disease activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Concerned overall with reducing or stopping MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (43.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e62.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Concerned about risk of flare when reducing or stopping MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.03\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e63.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Concerned about worsening when reducing or stopping MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e63.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.034\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Skipped or forgotten to take MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenn State Health (rural)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllegheny Health Network (urban)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (41.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e66.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears on MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears with RA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e: SD =standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*\u003cem\u003ep\u003c/em\u003e-value from chi-square test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e**\u003cem\u003ep\u003c/em\u003e-value from two-sample t-test (age) or Wilcoxon rank sum test (years on MTX, years with RA)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProvider perspectives\u003c/h3\u003e\n\u003cp\u003eTwenty-four providers (16 AHN; 8 PSH) completed the survey with a100% response rate. Ten providers (42%) had been practicing rheumatology for \u0026ge;\u0026thinsp;15 years (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Variables in favor of or against tapering were ranked by importance, from 1 (very important) to 5 (least important). When comparing rankings between AHN and PSH providers, we found no significant differences (not shown). Comparing the group of providers with \u0026lt;\u0026thinsp;15 years of experience (n\u0026thinsp;=\u0026thinsp;14) to those with greater experience, significant differences were found for two variables\u0026mdash;concurrent DMARD therapy and patient preference (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of the five variables in favor of tapering, only concurrent DMARD was considered significantly more important by providers who had been practicing for longer (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019). The importance of achieving remission, risks of long-term medication use, and patient noncompliance with monitoring did not significantly differ between providers. For the six variables against tapering, providers with more experience viewed patient preference as significantly less important than those with less experience (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). Importance ratings for radiographic progression, multiple treatment failures, and challenges regaining remission after flare did not differ significantly.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the mean importance ratings of the factors influencing providers\u0026rsquo; tapering decision between with \u0026lt;\u0026thinsp;15 years in practice (YIP) and those with \u0026ge;\u0026thinsp;15 YIP.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15 YIP (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15 YIP (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean Importance Rating*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables in favor of tapering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStable remission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisks of long-term MTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoncompliance with monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient preference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn concurrent DMARD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables against tapering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk of flare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient preference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty of recapturing remission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailed multiple previous therapies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk of radiographic progression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMTX useful to reduce immunogenicity or boost effect of bDMARD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: bDMARD: biologic disease-modifying, anti-rheumatic drugs; DMARD: disease-modifying, anti-rheumatic drugs *The importance rating scale ranged from 1 very important to 5 being least important. The mean value of the responses was calculated and presented here.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, surveys of RA patients and providers in two academic centers about MTX tapering found MTX tapering was more often attempted in male patients, patients treated at AHN, and patients with stable disease activity, long-term disease (\u0026gt;\u0026thinsp;6 years), and \u0026gt;\u0026thinsp;8 years of MTX use. Female patients with well-controlled RA were less likely to consider tapering and more concerned about the associated risks than their male counterparts. Greater concern of worsening disease and risk of flare was also observed in patients with \u0026gt;\u0026thinsp;8 years of MTX use. Furthermore, older patients were more likely to adhere to prescribed regimens. We also found rheumatology providers with \u0026lt;\u0026thinsp;15 years of experience were more likely to suggest MTX tapering to patients on concurrent DMARD therapy and considered patient preference less important than providers with more experience.\u003c/p\u003e \u003cp\u003ePrevious studies on RA patient preferences report patients and providers to have concerns regarding increased risk of flares during DMARD tapering. For example, one study found patients were receptive to recommendations of medication dose reduction but expressed concerns about flare risks with tapering and the need for timely provider communication and a clear plan if tapering was unsuccessful.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Another study investigating patient and rheumatologist perspectives on tapering DMARDs in RA found while acknowledging the potential benefits of tapering such as reducing side effects, both the patients and physicians interviewed in the study were cautious, noting lack of evidence.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Fear of flare and time it would take to return to a stable low activity state remains an obstacle for patients and providers in DMARD tapering decisions.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In our study, RA patients that had been treated with MTX\u0026thinsp;\u0026gt;\u0026thinsp;8 years were more likely to be concerned about the risk of flares and worsening disease. Additionally, male patients were more likely to consider MTX tapering as female patients were more concerned about the risks associated with tapering. The AHN team has previously reported on the risk of flare in RA patients who had well-controlled disease.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In this real-world cohort comparing tapering of different medications, flare rates were lowest while tapering in those on conventional synthetic DMARDs, such as MTX, compared to bDMARDs.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe official guidelines for RA treatment recommend gradual discontinuation of MTX under certain conditions and with little evidence.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Rheumatologists may be more likely to consider tapering or discontinuing DMARD therapy in their stable patients, but there are currently no strong guides for the best timing or strategies for tapering, and treatment is individualized to each patient and circumstance. This lack of strong guidelines leads to variation in provider preferences and decision making when considering MTX tapering. We found few differences in the importance ratings of variables influencing MTX tapering decisions between providers at AHN and PSH and those with different experience levels. However, providers with less experience (\u0026lt;\u0026thinsp;15 years practicing rheumatology) were more likely to suggest MTX tapering to patients on concurrent DMARD therapy and considered patient preference less important than providers with more experience.\u003c/p\u003e \u003cp\u003eThis study has several strengths and limitations. Strengths include the inclusion of patients in both rural and urban settings for a broader view of MTX tapering in patients from different geographic locations. Providers with different backgrounds/education (advanced practice providers vs. medical physicians) and years in practice were included. Pre-determined standardized responses were used in the surveys to make data collection and interpretation more uniform. Notably, data collection occurred during the COVID-19 pandemic for which heightened awareness of the effect of medications on disease and health could have raised patient awareness about tapering issues. Limitations include a lack of patient diversity with most patient respondents being White, selection bias in the clinics chosen to participate in the survey, and recall bias on behalf of the patient in choosing how to answer the questions about their years on MTX and years of diagnosis. Finally, since we did not collect the number of total patients asked to complete the survey vs. the number collected; an accurate survey response rate could not be determined.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePatients generally do not wish to take more medication than needed, and patient preferences on medication tapering or discontinuation in stable disease are important for shared decision making. Some of the results in our study are not unexpected, but pursuing guided strategies that are likely to succeed in medication dose reduction will require further study. Studies including patient and provider preferences on taper, especially studies such as this that build upon prior studies and validate prior thoughts and findings are needed. Furthermore, these results strongly suggest shared decision making among patients and providers to taper or discontinue medications including MTX will be critical to successful outcomes and provide a good starting point for future designed patient care standardized tapering guidelines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRheumatoid Arthritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDMARD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisease Modifying Anti Rheumatic Drug\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTX\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMethotrexate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecsDMARD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econventional synthetic Disease Modifying Anti Rheumatic Drug\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ebDMARD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebiologic Disease Modifying Anti Rheumatic Drug\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003etsDMARD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etargeted synthetic Disease Modifying Anti Rheumatic Drug\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePenn State Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAllegheny Health Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003eThis study was approved by the Institutional Review Boards of the Pennsylvania State University and the Allegheny Health Network and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cb\u003eCompeting Interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe author(s) declare(s) that they have no competing interests.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFunding\u003c/strong\u003e \u003cp\u003eThis project was supported by funding from Highmark Health and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1 TR002014. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH and Highmark Health\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.N. and S. B and N.O. and R. J. wrote main manuscript, contributed to study design, IRB approval and patient recruitment at Penn State HealthE.L and V. R. and G. S. contributed statistical support, study design and data entryP.N contributed to data entryT. S and N. W. and G. S. contributed to Study design, and patient recruitment and data entry at Allegheny HealthP. N. contributed to table and figure development and preparationAll authors reviewed manuscript and approved the final manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The authors thank Sarah Carey, MS, and Jacalyn Newman, PhD, of Allegheny Health Network\u0026rsquo;s Health System Publication Support Office (HSPSO) for their assistance in editing and formatting the manuscript. The HSPSO is funded by Highmark Health (Pittsburgh, PA, United States of America), and all work was done in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData have restricted access due to inclusion of protected health information but are available upon request to the corresponding author for an anonymized dataset.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001;358(9285):903\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Matteo A, Bathon JM, Emery P. Rheumatoid arthritis. Lancet. 2023;402(10416):2019\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFraenkel L, Bathon JM, England BR, et al. 2021 American college of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021;73(7):924\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuanda FT, Blake PG, Weir MA, et al. Low-dose methotrexate and serious adverse events among older adults with chronic kidney disease. JAMA Netw Open. 2023;6(11):e2345132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanoodi M, Mittal M, Methotrexate. 2025. In: StatPearls [Internet] [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK556114/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK556114/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKjorholt KE, Sundlisaeter NP, Aga AB, et al. Effects of tapering conventional synthetic disease-modifying antirheumatic drugs to drug-free remission versus stable treatment in rheumatoid arthritis (arctic rewind): 3-year results from an open-label, randomised controlled, non-inferiority trial. Lancet Rheumatol. 2024;6(5):e268\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma T, Banks S. Medication tapering in stable rheumatoid arthritis: Where do we stand and what work needs to be done? Rheumatology (Oxford). 2023;62(Suppl4):iv1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHazlewood GS, Loyola-Sanchez A, Bykerk V, et al. Patient and rheumatologist perspectives on tapering dmards in rheumatoid arthritis: A qualitative study. Rheumatology (Oxford). 2022;61(2):606\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiemer N, Webster P, Attur M, et al. Patient perspectives on tapering biologic or targeted synthetic therapy in well-controlled rheumatoid arthritis and comparison with providers' perspectives. Rheumatology (Oxford). 2023;62(Suppl4):iv3\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsiao B, Fraenkel L. Patient preferences for rheumatoid arthritis treatment. Curr Opin Rheumatol. 2019;31(3):256\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTageldin M, Wilson N, Yin Y, Sharma TS. A real-world 2-year prospective study of medication tapering in patients with well-controlled rheumatoid arthritis within the rheumatoid arthritis medication tapering (rheumtap) cohort. Rheumatology (Oxford). 2023;62(Suppl4):iv8\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brhm","sideBox":"Learn more about [BMC Rheumatology](http://bmcrheumatol.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/brhm/default.aspx","title":"BMC Rheumatology","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"rheumatoid arthritis, methotrexate, medication tapering, patient preference, provider preference","lastPublishedDoi":"10.21203/rs.3.rs-9142998/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9142998/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Current treatment guidelines for rheumatoid arthritis (RA) favor discontinuation of methotrexate (MTX) over biologic (b) DMARDs. To assess acceptability of this approach, we conducted a cross-sectional study evaluating the perspectives of patients and providers on MTX tapering at one urban and one rural health care center.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRheumatologists and patients were surveyed at the two health centers, one in an urban location and one with a predominantly rural service area. Patient surveys collected demographics, history of MTX use, and views on tapering. Provider surveys included questions about years of rheumatology practice and strategies being employed for tapering. Data were analyzed using chi-square and Wilcoxon rank sum tests in both questionnaire groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSurveys were collected over a 3 year period, from January 2020 through the end of 2022. Of the 143 patient respondents, 78% female and 86% were White. Median duration of RA was 12 years. Tapering trials of MTX were more frequent at the urban facility (p\u0026thinsp;=\u0026thinsp;0.02) and were more often considered in males with stable disease activity (p\u0026thinsp;=\u0026thinsp;0.005, and p\u0026thinsp;=\u0026thinsp;0.042,) and those with longer disease duration. Tapering concerns were greater for female patients on MTX for at least 8 years (p\u0026thinsp;=\u0026thinsp;0.046). Surveys collected from 16 urban providers and 8 rural providers showed that those with less than 15 years of experience were more likely to consider tapering if patients were concurrently on other treatments favorable for tapering (p\u0026thinsp;=\u0026thinsp;0.019) and were likely to consider patient preferences against tapering (p\u0026thinsp;=\u0026thinsp;0.004). None of the other differences between the two centers were significant.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe identified factors influencing tapering decisions for both patients and rheumatology providers, including age, race, sex, RA duration and provider\u0026rsquo;s years of experience. Consideration of these will facilitate designing acceptable future approaches to MTX tapering in patients with stable RA.\u003c/p\u003e","manuscriptTitle":"Tapering or Discontinuation of Methotrexate in Stable Disease- Opinions From Rheumatoid Arthritis Patients and Rheumatology Providers at Two Academic Healthcare Centers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 14:40:58","doi":"10.21203/rs.3.rs-9142998/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-15T19:59:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-14T16:38:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292539230503677469111596670094642069824","date":"2026-05-14T16:30:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142458185206033482545725604362578857644","date":"2026-04-06T20:13:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124297334831458424938186534187414292294","date":"2026-04-06T15:44:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T13:07:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178097654447493690262728991325491032893","date":"2026-04-04T12:42:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T03:10:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T01:03:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T14:36:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-29T22:00:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Rheumatology","date":"2026-03-29T21:56:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brhm","sideBox":"Learn more about [BMC Rheumatology](http://bmcrheumatol.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/brhm/default.aspx","title":"BMC Rheumatology","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c606486a-e599-46e9-8d42-772d9fd91dc7","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-15T19:59:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-14T16:38:24+00:00","index":56,"fulltext":""},{"type":"reviewerAgreed","content":"292539230503677469111596670094642069824","date":"2026-05-14T16:30:25+00:00","index":55,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T20:09:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 14:40:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9142998","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9142998","identity":"rs-9142998","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}