The Treat-to-Target Model in RA

The treat-to-target approach represented a stepped-up model for chronic disease management that only became possible when the available therapies showed the potential for disease remission. The treat-to-target model offered a much more aggressive approach designed to achieve such goals, whereby increases in disease activity—or failure to remit—are met with escalating therapies.

Escalating to target, however, is not the only feature of the treat-to-target approach. Daniel H. Solomon, MD, MPH, Chief of the Section of Clinical Sciences and Co-Director of the Center for Patient-Centered Comparative Effectiveness Research (PCCER) at Brigham and Women’s Hospital in Boston, Massachusetts, reported that conversely,  “A treat-to-target approach… allows for different RA treatment targets when remission is not achievable.”


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Based on success in other chronic disease areas including diabetes, hypertension, and hyperlipidemia, research from several clinical trials conducted over the past 10 to 15 years has indicated that treating to a specific target in RA provides superior results compared with standard treatment protocols.5 “Treat to target is also an important paradigm for two additional reasons,” Dr Solomon said, “First, it requires shared decision making between patient and provider to pick or modify a target and treatments.  Second, it requires that providers record a standardized disease activity measure at all visits.”

In a review published in Arthritis and Rheumatology, Dr Solomon and colleagues identified several barriers to acceptance of the treat-to-target strategy, the most notable of which is that RA has largely patient-reported symptomatology, which is highly subjective and difficult to measure.5

A second obstacle is that treatments with DMARDS and other RA drugs can have substantial serious adverse effects ranging from immune system effects to black box warnings about cancer and decreased resistance to infections, making it important to identify the right treatment for each patient and to monitor response. Discussions about potentially serious adverse effects may add to the patient’s perception of risk, Dr Solomon pointed out, thereby increasing resistance to modifying dose or changing therapies as warranted. 5

One of the greatest challenges is identification of the targets themselves. The 2015 ACR guidelines recommend that the “ideal target should be low disease activity or remission, as determined by the clinician and the patient.”3 This target will vary on a case-by-case basis according to those measuring the outcomes and may be modified by the presence of comorbidities and variations in patient risk tolerance.

References

  1. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheumatol. 2008;59:762-784. 
  2. Graudal N, Hubeck-Graudal T, Faurschou M, Baslund B, Jeurgens G. Combination therapy with and without tumor necrosis factor inhibitors in rheumatoid arthritis: a meta-analysis of randomized trials. Arthritis Care Res. 2015;67(11):1487-1495.
  3. RA Treatment Guidelines: Appendix 5. American College of Rheumatology website. Available at: http://www.rheumatology.org/Portals/0/Files/ACR%20RA%20GL%20
    Supplementary%20Appendix%205%20Exec%20Summary.pdf. Accessed December 10, 2015.
  4. Smolen JS, Landewé R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014;73:492-509. 
  5. Solomon DH, Bitton A, Katz JN, et al. Treat to target in rheumatoid arthritis. fact, fiction or hypothesis? Arthritis Rheumatol.  2014;66:775-782.