Target-To-Treat Approach Beneficial for Rheumatoid Arthritis Treatment

Treat-to-target has largely become the preferred method for physicians treating patients with rheumatoid arthritis.

“I think there’s room for further data and evidence, but in general, I think we use this in our patients for the benefits of joint preservation, enhancing work productivity, improving quality of life, and enhancing the probability of remission,” said John M. Davis, MD, MS, vice chair of Rheumatology at Mayo Clinic.

Dr Davis gave a presentation about this topic at the ARHP Clinical Focus Course at the American College of Rheumatology and Association of Rheumatology Health Professionals annual meeting.

His presentation focused on the importance of this treatment for adults with the disease, as well as the updated ACR guidelines. He also discussed his own perspectives in managing rheumatoid arthritis and common comorbidities.

The main goal of treat-to-target is to have patients achieve remission quickly and safely. The goal of patients with severe rheumatoid arthritis may be to achieve low disease activity, Dr Davis said.

Treat-to-target requires physicians to measure a patient’s disease activity every 1 to 3 months until the desired outcome is reached, and then disease activity is measured every 3 to 6 months. If disease activity becomes unstable, it needs to be monitored more often, and treatment must be adjusted.

However, taking other medications, side effects, cost and health care burdens could also present limitations for this treatment, according to the session. The shift towards treat-to-target was due to the TICORA and BeST clinical trials, which were both conducted in the early 2000s.

At that time, the standard care was a pyramid scheme, Dr Davis said in the session. Physicians would initiate treatment with an NSAID or hydroxychloroquine and then wait 6 months before determining if the patient responded.

The newly-revised ACR guideline expands on an earlier version of the guidelines, now recommending treat-to-target for these patients. The new recommendations were revised using the GRADE methodology that uses a transparent and aggressive assessment of evidence.

Recommendations of treatments are categorized as strong or conditional. A strong recommendation means that a majority of patients should receive it and conditional means that there should be an open discussion about whether this is a beneficial treatment option, according to the session.

The session also discussed what physicians should do if their patients do not achieve the treatment goal, or do not respond to the treatment. For patients who do not respond optimally to methotrexate, there are other strong recommendations for treatments based on clinical trials, and there are also conditional recommendations for patients who fail to respond.

When patients experience treatment failure, barriers to care must be discussed. Factors such as medication adherence, caregiver support, smoking, weight, mental health conditions, and a wrong diagnosis should be discussed in this care, Dr Davis said.

Another issue that can also contribute to depression is if patients and physicians are not in agreement about the disease. If patients believe their disease is less or more severe than their physician does, this discordance can increase the risk of depression.

“Both situations can be problematic, although I think the one that is most challenging for us is the situation in which the patient is struggling and having high levels of pain and disability,” Dr. Davis said.

By implementing a treat-to-target strategy and understanding the new guidelines, physicians have an increased ability to treat patients in the most beneficial manner.