Treat-to-Target Approaches in RA Assessed in Systematic Review

Targeting SDAI/CDAI may be superior to that of DAS-LDA in clinical outcomes in RA treatment.

A treat-to-target (T2T) approach for rheumatoid arthritis (RA) using Simplified Disease Activity Indices (SDAI)/Clinical Disease Activity Indices (CDAI) were found to be superior to other targets in achieving favorable clinical outcomes, according to study findings published in RMD Open.

Using a systematic review and meta-analysis, researchers compared the efficacy of different T2T targets in the treatment of RA.

Researchers from UMC Utrecht in the Netherlands searched publication databases through June 2022 for studies using T2T in the setting of RA.

A total of 66 articles including 169 treatment arms were included in the review, of which 52 articles and 114 arms, respectively, were included in the meta-analysis.

A total of 62.3% of studies used a Disease Activity Score-28 (DAS28)/Low Disease Activity (LDA) target; 31.6% used a DAS28/remission target; and 6.1% a SDAI/CDAI-LDA target. The studies were published between 2016 to 2022 (57.9%), 2010 to 2015 (30.7%), and 2003 to 2009 (11.4%).

The pooled sample included 70.0% women, with a mean age of 54.3 (SD, 4.6) years, a DAS of 5.0 (SD, 0.8), Health Assessment Questionnaire (HAQ) of 1.2 (SD, 0.3), and median Sharp van der Heijde Score (SHS) of 3.0 at baseline.

Based on our results SDAI-LDA or CDAI-LDA would be the LDA-target of choice, although DAS (28)-LDA may be an alternative as it is the most commonly used.

For percentage of DAS-remission, SDAI/CDAI-LDA was significantly favorable vs DAS28/LDA among patients who achieved DAS remission. The percentage of patients who achieved DAS-remission at 2 to 3 years was 21% higher with a DAS28/remission target compared with a DAS-28/LDA target (P =.03). However, the difference was not significant at 4 to 6 years (P =.53).

For the outcome of SDAI/CDAI, targeting SDAI/CDAI associated with a 5.08-unit improvement (P =.03) at 1 year compared with a DAS28/remission target and a 2.03-unit improvement (P =.23) compared with DAS28/LDA. Targeting DAS28/remission tended to be worse than targeting DAS28/LDA (-3.05 units; P =.06).

Targeting SDAI/CDAI-LDA was favorable for the outcome of SDAI/CDAI/Boolean remission compared with DAS28/LDA at 1 (34%; P =.05) and 2 to 3 years (31%; P =.0002) and compared with DAS28/remission at 1 (35%; P =.03) and 2 to 3 years (36%; P <.0001).

After 1 to 3 years of T2T, for the outcome of DAS-estimated sedimentation rate (ESR), targeting SDAI/CDAI-LDA or DAS28/remission was favorable vs DAS28/LDA. No trends were observed for SHS, HAQ, or C-reactive protein outcomes.

Trends were similar across subgroups, though it was more pronounced among the established-RA subgroup, except that a significant interaction was observed for the DAS-remission model (P =.01), in which effects were amplified among the established RA subgroup.

A major limitation of the analysis was that trends were collected through indirect comparisons. Head-to-head trials are needed to confirm these findings.

The study authors concluded, “Based on our results SDAI-LDA or CDAI-LDA would be the LDA-target of choice, although DAS (28)-LDA may be an alternative as it is the most commonly used.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Messelink MA, den Broeder AA, Marinelli FE, et al. What is the best target in a treat-to-target strategy in rheumatoid arthritis? Results from a systematic review and meta-regression analysis. RMD Open. 2023;9(2):e003196. doi:10.1136/rmdopen-2023-003196