Objective To describe the perspectives of patients with chronic inflammatory rheumatic diseases (CIRD) regarding osteoporosis, falls and fractures in order to develop a theoretical framework to explain healthcare perceptions and key impacts, which may guide development of consumer-focussed interventions to improve care. Methods Patients ≥ 50 years with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis or systemic lupus erythematosus and a concurrent diagnosis of osteoporosis were purposively sampled from two rheumatology services based in metropolitan tertiary hospital to participate in a focus group or interview. Transcripts were thematically analysed. Results Six main themes were identified: Ambivalence towards diagnoses, changing identity and loss of confidence, complexities of management in rheumatic disease, embracing own health autonomy, entrusting care in healthcare providers and expectations for proactive care. Conclusion Patients living with CIRD may be ambivalent to osteoporosis, falls and fractures, but also fearful of the consequences to their identity and function. They value proactive care from their clinicians that addresses osteoporosis and falls prevention. Many feel their educational needs around these risks are unmet and look to clinicians for support that empowers them, fosters acceptance and acknowledges the potential threat these conditions post to independence and identity. Future interventions should incorporate patient-centred educational models and provide clinicians with the resources needed to offer meaningful preventive care.

Osteoporosis and falls are major risk factors for osteoporotic fractures, with significant detriment to patients’ quality of life. We aimed to describe healthcare provider (HCP) perspectives and experiences in the diagnosis, management and prevention of osteoporosis, falls and fractures obtained through primary qualitative research. Thematic synthesis was performed on articles identified through a search of electronic databases (MEDLINE, Embase, PsychINFO and CINAHL), which were searched from inception to May 2023. Twenty-seven studies including 1662 HCPs, including general practitioners (GPs), physicians, surgeons, physiotherapists (PTs), occupational therapists (OTs), pharmacists and nurses, were included, with identification of six themes: overshadowed as a disease entity, uncertainty in decision making, frustration with interdisciplinary and systemic tension, avoiding medical paternalism, desire for improved care and embracing the responsibility. Osteoporotic fracture and fall prevention in routine clinical care is hampered by inadequate priority and lack of perceived connection with morbidity and mortality, deficits in interdisciplinary collaboration, lack of clinical confidence and health resourcing. However, HCPs acknowledge their role in promoting healthy ageing, thus providing support through appropriate continuing education, resourcing and public health campaigns that are significant future directions, which may improve osteoporotic fracture prevention.

Psoriatic arthritis (PsA) is a progressive, systemic inflammatory disease. It can lead to serious joint damage and disability, increased cardiovascular risk and reduced quality of life. Six experts met to develop the recommendations for the management of PsA in Australia. The final recommendations are approved by all panel members. Management and treatment recommendations have been made under six subheadings: Recommendations for non-steroidal anti-inflammatory drugs and glucocorticoids; Disease-modifying treatment; Screening and monitoring; Family planning; Symptom treatment and extra-articular manifestations; Comorbidities and lifestyle considerations. Our recommendations for the management of PsA in Australia draw heavily on the established global guidelines. These recommendations aim to assist clinicians to make informed, patient-centric choices when delivering treatment to people with PsA.

Background Guselkumab (GUS) is a novel anti-interleukin 23 (IL-23)p19 antibody that acts as a selective and specific inhibitor of the IL-23 cytokine. GUS has been shown to significantly improve signs and symptoms of active psoriatic arthritis (PsA) and became available for the treatment of PsA in Australia in July 2021. Limited data from large real-world patient populations exist to describe the utilisation of GUS for the management of PsA. Objectives To describe the patient demographics and treatment patterns of GUS in a large real-world cohort of Australian adult patients with PsA. Methods The OPAL dataset is a collection of deidentified clinical data derived from the electronic medical records of 112 rheumatologists at 43 sites around Australia. Adult patients with a diagnosis of PsA who received at least one prescription of GUS or a biologic or targeted synthetic disease modifying anti-rheumatic drug (b/tsDMARD) between Jul 2021 and Jul 2022, were eligible for inclusion in the analysis. Results were summarised descriptively. Results A total of 1,868 patients with PsA, (GUS n=355, TNFi n=795, IL-17Ai n=371 and JAKi n=347) were eligible for inclusion in this study. The median [IQR] age of patients was 55 [44-63] years, and 70.1% were female. At baseline, median disease duration was 5[2-8], 2[1-6], 3[1-7] and 5[3-8] years, for patients treated with GUS, TNFi, IL-17Ai and JAKi, respectively. 17.7% of patients receiving GUS were first line compared with 58.7% of TNFi, 39.4% of IL-17Ai and 19.3% of JAKi treated patients (Table 1). At index, the majority of patients were treated as monotherapy. Conclusion These are the first data describing the demographics and treatment patterns of real-world Australian patients with PsA treated with GUS. In this preliminary analysis, a higher proportion of GUS and JAKi were used in later lines of therapy, and patients who initiated GUS or JAKi had a longer median disease duration. This may be due to the different time periods of availability of the different b/tsDMARD, as both GUS and JAKi are newer treatment options for PsA compared with TNFi and IL17Ai. Persistence among patients with PsA treated with GUS is currently being investigated. Acknowledgements The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform. This study was conducted with financial support provided by Janssen Australia. Disclosure of Interests Geoff Littlejohn: None declared, Nithila Anbumurali: None declared, Paul Bird Speakers bureau: GSK, AbbVie, Janssen, Eli-Lilly, Consultant of: AbbVie, Janssen, Pfizer, Eli-Lilly, GSK, BMS, Peter Youssef: None declared, Catherine OSullivan: None declared, Tegan Smith: None declared, Daniel Sumpton: None declared, Barry Kane: None declared, Andrew McGeachie Employee of: Current employee of Janssen Australia, Stefanie Spiers Employee of: Current employee of Janssen Australia, Claire Deakin: None declared.Table 1Demographic features of patients with psoriatic arthritis treated with GUS, TNFi, IL-17Ai or JAKi as any line of therapy.FeatureInitiators of GUS (n=355)Initiators of TNFi (n=795)Initiators of IL-17Ai (n=371)Initiators of JAKi (n=347)Gender, Female (n, %)250 (71.3%)538 (69.2%)240 (67%)251 (73%)Age at Index, years (median [IQR])55 [45-63]51 [41-61]54 [45.5-64]55 [48-64]Duration of disease recorded in Audit4 at Index, years (median [IQR])5 [2-8]2 [1-6]3 [1-7]5 [3-8]Line of therapy (n, %)Line 163 (17.7%)467 (58.7%)146 (39.4%)67 (19.3%)Line 257 (16.1%)152 (19.1%)99 (26.7%)81 (23.3%)Line 3+235 (66.2%)176 (22.1%)126 (34%)199 (57.3%)GUS; guselkumab.

Thyroxine, dibutyryl cyclic AMP, and a combination of both drugs were administered daily from birth to 2, 2 and 3 pups, respectively from each of 5 litters of Sprague-Dawley rats. Body weight, brain weight, cerebellar weight, and cerebellar DNA were measured in each animal at age 5 days and compared with values from a pair of controls from each litter. Cerebellar weight and DNA content were affected more severely than body weight in cyclic AMP-treated animals, with cerebellar DNA reduced significantly to 88% of control values. Cerebellar DNA was significantly elevated to 117% of control values in thyroxine-treated animals. This augmentation of cerebellar DNA synthesis by thyroxine was negated by administration of dibutyryl cyclic AMP 10 min prior to the thyroxine injection. These results support an hypothesis that the enhancement of cerebellar cell division by thyroxine involves an increase in the ratio of intracellular cyclic guanosine monophosphate to cyclic adenosine monophosphate. The reversal of the thyroxine-induced increase in cerebellar DNA synthesis by a prior injection of dibutyryl cyclic AMP suggests that the early stimulation of cell division by thyroxine may be mediated by cyclic AMP, and that the intracellular balance between cerebellar cyclic AMP and cyclic GMP was distorted by in vivo elevation of intracellular cyclic AMP levels.

A treat-to-target strategy is recommended for management of psoriatic arthritis (PsA), although there is lack of agreement regarding the best measure of disease activity to target. Physician assessments included in traditional indices can be complex and time consuming to complete and cannot be readily conducted by telehealth. This study compares the routine assessment of patient index data 3 (RAPID3), an efficient tool comprising patient self-assessment, with traditional clinician-led composite measures in the PsA clinic setting. Data were collected prospectively from July 2016 to March 2020 in 2 dedicated PsA clinics in Sydney, Australia. A receiver operating characteristic (ROC) curve was created for comparison of RAPID3 score with composite scores minimal disease activity (MDA), very low disease activity (VLDA) and disease activity in psoriatic arthritis (DAPSA) in low disease activity or remission. Ninety-three patients had simultaneous collection of RAPID3 and MDA measures. Mean (SD) age was 49.9 (13.5) years, 50.5% were male and 23 (24.7%) had erosive disease at baseline. RAPID3 scores ≤3.2 and ≤2.7 (range 0-30) had high sensitivity and specificity for VLDA and DAPSA remission respectively, with ROC curve area under the curve (95% CI) of 0.94 (0.91-0.97) and 0.96 (0.93-0.99). RAPID3 has good agreement with physician-led composite scores of MDA, VLDA and DAPSA, and provides a viable alternative to composite scores. This is particularly helpful in settings that do not allow for clinical examination, for example telehealth.

VEXAS is a newly recognised adult-onset autoinflammatory syndrome resulting from a somatic mutation in the UBA1 gene. Herein, we present three cases of VEXAS syndrome in Sydney, Australia, that capture key clinical features and the refractory nature of the condition. They highlight the importance of multidisciplinary collaboration for early diagnosis and the need for new therapeutic options.

We aimed to assess patient preferences for the characteristics and outcomes of biologic and targeted synthetic disease‐modifying antirheumatic drugs (DMARDs) to manage psoriatic arthritis.

Objective Dermatomyositis (DM) and juvenile dermatomyositis (JDM) are idiopathic inflammatory myopathies, which can be resistant and unresponsive to initial treatments, leading to severe complications and impaired quality of life. There are few randomised trials in dermatomyositis and the outcomes reported may not be consistent, which can limit decision-making. The aim of this study is to assess the scope and consistency of outcomes reported in randomised trials in dermatomyositis. Methods MEDLINE, Embase, PsycINFO and clinicaltrials.gov were searched from 1993-2020 for randomised trials in children and adults with dermatomyositis. The frequency and characteristics of the outcomes reported were analysed and classified. Results 20 trials were included. Across these trials, a total of 743 outcome measures were reported, which were grouped into 34 outcome domains; of which 17 were clinical, 13 were surrogate/biochemical, and 4 were patient-reported outcomes. The top five most frequently reported outcome domains were muscle inflammation (15 trials, 46 outcome measures), physical function (14 trials, 16 outcome measures), muscle strength (13 trials, 30 outcome measures), global health (12 trials, 33 outcome measures) and immunologic marker (11 trials, 91 outcomes). Conclusion The majority of outcomes reported in trials in people with dermatomyositis and JDM are clinical and surrogate outcomes rather than patient-reported outcomes. The outcomes reported are very inconsistent across trials, with wide heterogeneity in the measures used. Standardised reporting of critically important outcomes is needed to strengthen the value of trials for decision-making.

OBJECTIVE:Decision-making regarding medications to manage psoriatic arthritis (PsA) is complex because of multiple disease manifestations and comorbidities. Fear of side effects from systemic medications and misalignment in priorities between patients with PsA and rheumatologists makes shared decision-making challenging. We aimed to describe the perspectives of patients with PsA on shared decision-making regarding medication taking.METHODS:Face-to-face semistructured interviews were conducted with 25 adult patients with PsA in Australia. Transcripts were thematically analyzed.RESULTS:Five themes were identified: lacking agency in decision-making (denied choice, knowledge asymmetry, desperation and necessity, restricted by unfair eligibility criteria, automated approach); overwhelmed by potential harms (daunted by aggressive therapy, anticipating lifestyle disruption from side effects, jeopardizing fertility and pregnancy, avoiding relapse); gaining confidence (discernible benefit in function and mental health, sharpening knowledge over time, expertise of family and peers, empowered by information); opting for alternatives (pursuing normality, suspicion of over-medicalization, seeking comprehensive solutions); and developing trust and fortifying collaboration (assurance through a personable approach, seeking consistency, supported in decisional power, resolution through respectful negotiation).CONCLUSION:Patients with PsA lack agency in making treatment decisions and are overwhelmed by the potential harms of systemic medication. Improving knowledge and trust with medical teams in a supportive and collaborative environment, and strategies for managing risks and side effects may improve decision-making about pharmacologic management of PsA.

VEXAS is a newly recognised adult-onset autoinflammatory syndrome resulting from a somatic mutation in the UBA1 gene. Herein, we present three cases of VEXAS syndrome in Sydney, Australia, that capture key clinical features and the refractory nature of the condition. They highlight the importance of multidisciplinary collaboration for early diagnosis and the need for new therapeutic options.

Objective This study aimed to identify and prioritize factors important to patients and caregivers with regard to medication adherence in gout, osteoporosis (OP), and rheumatoid arthritis (RA) and to describe the reasons for their decisions. Methods Patients with gout, OP, and RA and their caregivers, purposively sampled from 5 rheumatology clinics in Australia, identified and ranked factors that they considered important for medication adherence using nominal group technique and discussed their decisions. An importance score (IS; scale 0-1) was calculated, and qualitative data were analyzed thematically. Results From 14 focus groups, 82 participants (67 patients and 15 caregivers) identified 49 factors. The top 5 factors based on the ranking of all participants were trust in doctor (IS 0.46), medication effectiveness (IS 0.31), doctor's knowledge (IS 0.25), side effects (IS 0.23), and medication-taking routine (IS 0.13). The order of the ranking varied by participant groupings, with patients ranking "trust in doctor" the highest, while caregivers ranked "side effects" the highest. The 5 themes reflecting the reasons for factors influencing adherence were as follows: motivation and certainty in supportive individualized care; living well and restoring function; fear of toxicity and cumulative harm; seeking control and involvement; and unnecessarily difficult and inaccessible. Conclusion Factors related to the doctor, medication properties, and patients' medication knowledge and routine were important for adherence. Strengthening doctor-patient trust and partnership, managing side effects, and empowering patients with knowledge and skills for taking medication could enhance medication adherence in patients with rheumatic conditions.

Patient-centered care is widely advocated in rheumatology. This involves collaboration among patients, caregivers, and health professionals and is particularly important in chronic rheumatic conditions because the disease and treatment can impair patients' health and well-being. Qualitative research can systematically generate insights about people's experiences, beliefs, and attitudes, which patients may not always express in clinical settings. These insights can address complex and challenging areas in rheumatology, such as treatment adherence and transition to adult healthcare services. Despite this, qualitative research comprises 1% of studies published in top-tier rheumatology journals. A better understanding about the effect and role, methods, and rigor of qualitative research is needed. This overview highlights the recent contributions of qualitative research in rheumatology, summarizes the common approaches and methods used, and outlines the key principles to guide appraisal of qualitative studies.

OBJECTIVE:Nonadherence to medications is common in rheumatic conditions and associated with increased morbidity. Heterogeneous outcome reporting by researchers compromises the synthesis of evidence of interventions targeting adherence. We aimed to assess the scope of outcomes in interventional studies of medication adherence.METHODS:We searched electronic databases to February 2019 for published randomized controlled trials and observational studies of interventions with the primary outcome of medication adherence including adults with any rheumatic condition, written in English. We extracted and analyzed all outcome domains and adherence measures with prespecified extraction and analysis protocols.RESULTS:Overall, 53 studies reported 71 outcome domains classified into adherence (1 domain), health outcomes (38 domains), and adherence-related factors (e.g., medication knowledge; 32 domains). We subdivided adherence into 3 phases: initiation (n = 13 studies, 25%), implementation (n = 32, 60%), persistence (n = 27, 51%), and phase unclear (n = 20, 38%). Thirty-seven different instruments reported adherence in 115 unique ways (this includes different adherence definitions and calculations, metric, and method of aggregation). Forty-one studies (77%) reported health outcomes. The most frequently reported were medication adverse events (n = 24, 45%), disease activity (n = 11, 21%), bone turnover markers/physical function/quality of life (each n = 10, 19%). Thirty-three studies (62%) reported adherence-related factors. The most frequently reported were medication beliefs (n = 8, 15%), illness perception/medication satisfaction/satisfaction with medication information (each n = 5, 9%), condition knowledge/medication knowledge/trust in doctor (each n = 3, 6%).CONCLUSION:The outcome domains and adherence measures in interventional studies targeting adherence are heterogeneous. Consensus on relevant outcomes will improve the comparison of different strategies to support medication adherence in rheumatology.

Objective To describe the range and depth of perspectives and experiences of patients with psoriasis and psoriatic arthritis to inform gaps in patient-centered care. Methods We searched MEDLINE, Embase, PsycINFO, and CINAHL to April 2018. Thematic synthesis was used to analyze the findings. Results We included 56 studies involving 1,484 adult patients with psoriasis (n = 1,147) and psoriatic arthritis (n = 337). Six themes (and subthemes) were identified: suffering uncontrollable and ongoing upheaval (dictating life choices and course, disrupting family and social roles, limited by debilitating symptoms, unstoppable and far-reaching fatigue), weighed down by mental load (anxiety provoked by the volatility of symptoms, dreading deterioration, struggling with unrecognized distress, helpless and nihilistic), harboring shame and judgement (marked as unhygienic and contagious, rejected and isolated, hiding away and resenting own appearance, pain and embarrassment in intimacy), demoralized by inadequacies and burden of therapy (disappointed by unmet expectations of treatment benefit, daily drudgery, deterred by unpalatable or inconvenient treatments, disempowered by lack of personalized care), gaining control (making sense of the condition, accepting a new health status, regaining independence and normality, attuning to the body), and making confident treatment decisions (trading off perceptible benefits against safety and convenience, relying on family input, seeking empowering and reassuring relationships). Conclusion Patients with psoriasis and psoriatic arthritis contend with disruption in their functioning, roles, and life course and have unmet expectations about treatment. Enhanced therapeutic relationships, addressing treatment expectations and supporting psychosocial needs may improve satisfaction and outcomes.

While patient-centered care is widely advocated in the management of rheumatic diseases, it can be challenging to implement, particularly for patients with complex systemic conditions. Patient-centered care involves identifying and integrating the patient's experiences, attitudes, and preferences in decision-making. Qualitative research is used to describe patient perspectives and priorities that may not always be expressed in clinical settings. Systematic reviews of qualitative studies can provide new and more comprehensive evidence of patients' beliefs and priorities across different populations and healthcare settings and are increasingly being reported across medical specialties, including rheumatology. In rheumatology, they have been used to examine topics including medication-taking and adherence, coping with systemic sclerosis and conservative management and exercise in osteoarthritis. By referencing recent examples of systematic qualitative reviews in the rheumatology literature, this article will outline the methodology and methods used, and provide an approach to guide the appraisal of reviews. We aim to give the reader a practical understanding of systematic reviews of qualitative literature and elucidate how knowledge gained from such reviews can be applied to improve the care of patients with rheumatic conditions.

Objective The core outcome set for trials in systemic sclerosis (SSc) was developed in 2008 and comprises 11 domains and 31 measures, leading to the development of the Combined Response Index in Diffuse Cutaneous Systemic Sclerosis (CRISS). We aimed to assess the scope and consistency of outcomes reported in trials of SSc and the uptake of this core set and the CRISS. Methods Medline, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov were searched to identify randomized trials published from January 1, 2000 to April 29, 2018 in adults with limited or diffuse SSc. Outcomes and measures were recorded for each trial, classified into domains and the frequency of outcomes before after publication of the publication of the core set calculated. Results From 152 trials, 4,193 outcomes were classified into 84 domains. The 3 most common domains were health-related quality of life (HRQoL) and function (59%, 130 measures), skin (47%, 59 measures), and pulmonary (45%, 168 measures). After the publication of the core outcome set, no trial reported the complete core set with adherence to each of the 11 domains, ranging from 6.1% to 54.4% and adherence to each of the 31 measures ranging from 0% to 48.1%. The 5 measures required for the CRISS were reported completely in 11% of trials. Conclusion Despite recognition that uniform acquisition and reporting of outcomes would enable a better evaluation of proposed SSc therapeutics, the outcome domains and measures reported in randomized trials in SSc remain very inconsistent, with little impact of the core outcome set.

Internal Medicine JournalVolume 49, Issue 9 p. 1189-1190 Letter to the Editor Scurvy: a rare cause of arthralgia in a young woman Veronica C. K. Wong, Veronica C. K. Wong Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorGrace Yung, Grace Yung Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorRobert Russo, Robert Russo Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorDaniel Sumpton, Daniel Sumpton Department of Rheumatology, Concord Hospital, Sydney, New South Wales, Australia Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, AustraliaSearch for more papers by this authorRobert Mansberg, Robert Mansberg orcid.org/0000-0001-8237-9269 Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author Veronica C. K. Wong, Veronica C. K. Wong Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorGrace Yung, Grace Yung Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorRobert Russo, Robert Russo Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorDaniel Sumpton, Daniel Sumpton Department of Rheumatology, Concord Hospital, Sydney, New South Wales, Australia Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, AustraliaSearch for more papers by this authorRobert Mansberg, Robert Mansberg orcid.org/0000-0001-8237-9269 Department of Nuclear Medicine, Concord Hospital, Sydney, New South Wales, Australia Sydney Medical School, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 10 September 2019 https://doi.org/10.1111/imj.14427Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume49, Issue9September 2019Pages 1189-1190 RelatedInformation

OBJECTIVE:Nonadherence to disease-modifying antirheumatic drugs (DMARDS) in rheumatoid arthritis (RA) and spondyloarthritis (SpA) results in increased disease activity and symptoms and poorer quality of life. We aimed to describe patients' attitudes and experiences of DMARDs in RA and SpA to inform strategies to improve medication adherence.METHODS:Databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched to January 2016. Thematic synthesis was used to analyze the findings.RESULTS:From 56 studies involving 1,383 adult patients (RA [n = 1,149], SpA [n = 191], not specified [n = 43]), we identified 6 themes (with subthemes): intensifying disease identity (severity of sudden pharmacotherapy, signifying deteriorating health, daunting lifelong therapy), distressing uncertainties and consequences (poisoning the body, doubting efficacy, conflicting and confusing advice, prognostic uncertainty with changing treatment regimens), powerful social influences (swayed by others' experiences, partnering with physicians, maintaining roles, confidence in comprehensive and ongoing care, valuing peer support), privilege and right of access to biologic agents (expensive medications must be better, right to receive a biologic agent, fearing dispossession), maintaining control (complete ownership of decision, taking extreme risks, minimizing lifestyle intrusion), and negotiating treatment expectations (miraculous recovery, mediocre benefit, reaching the end of the line).CONCLUSION:Patients perceive DMARDs as strong medications with alarming side effects that intensify their disease identity. Trust and confidence in medical care, positive experiences with DMARDS among other patients, and an expectation that medications will help maintain participation in life can motivate patients to use DMARDs. Creating a supportive environment for patients to voice their concerns may improve treatment satisfaction, adherence, and health outcomes.