Update: 2017 Treat-to-Target Recommendations for Spondyloarthritis

A 2017 clinician task force has updated recommendations from 2012 regarding therapeutic targets for axial and peripheral spondyloarthritis (SpA) — including psoriatic arthritis (PsA) — based on a literature review and expert opinion. The recommendations were published in the Annals of Rheumatic Diseases.

Building on earlier efforts, the task force again utilized the treat-to-target concept as a framework for its clinical guidance, with the main therapeutic targets being remission or minimal disease activity. Using this paradigm, the task force developed 5 overarching principles, along with a set of 11 recommendations, all of which were included based on members’ anonymous electronic voting in which more than 75% of members voted affirmatively.

The task force was convened in order to refine the proposals from 5 years prior, as there had been substantial advances in research evidence and clinical appreciation of SpA since that time. While previously most suggestions came from expert opinion alone, the 2017 task force was also incorporated higher quality findings derived from more recent research and publications. The task force’s advice, as with most treat-to-target-focused counsel, is by its nature more generic and therefore does not deal with individualized patient therapies.

For both the overarching principles and recommendations, members voted on a scale of 0 to 10 based on their level of agreement. The results of this voting are presented as means and standard deviations next to each overarching principle or recommendation.

The 5 overarching principles were:

1. The treatment target should be the result of a joint decision between rheumatologist and patient (mean level of agreement 9.7±0.7)
2. Improved outcomes are realized when treat-to-target assesses disease activity and therapeutic changes are made accordingly (9.3±1.2)
3. Because SpA and PsA are complex systemic disorders, the rheumatologist should coordinate with other specialists in the management of extra-articular and musculoskeletal manifestations as needed (9.8±0.5)
4. For SpA and PsA, optimization of long-term quality of life and social participation are the goals of patient treatment, to be achieved via sign/symptom control, structural damage prevention, functional preservation/normalization, toxicity avoidance, and comorbidity minimization (9.9±0.3)
5. Reduction of inflammation is key in pursuit of these goals (9.2±1.8)

The 11 recommendations by the task force included:

1. Clinical remission or inactive disease should be the treatment target with in both musculoskeletal and extra-articular presentations (9.2±1.8)
2. Clinical indications should inform individual treatment targets, with consideration given to the treatment modality when determining the required time to achieve the targets (9.6±0.8)
3. The definition of remission should be the absence of laboratory and clinical evidence of disease (9.6±0.6)
4. If remission is not attainable an alternative treatment target should be minimal disease activity (9.6±0.9)
5. Clinical signs and symptoms, along with acute phase reactants, should be used to assess disease activity (9.3±0.9)
6. Definition of the treatment target and therapeutic guidance should be derived from validated instruments that measure musculoskeletal involvement and extra-articular and cutaneous manifestations, with disease activity level directing measurement frequency (9.4±0.8)
7. The Ankylosing Spondylitis Disease Activity Score (ASDAS) should be used to assess axial SpA (axSpA) and define treatment target; for PsA, the preferred measures are the Disease Activity Index for Psoriatic Arthritis (DAPSA) or observation of minimal disease activity (7.9±2.5)
8. Patient factors, comorbidities and medication-related risks should be considered when choosing the treatment target and appropriate measures of disease activity (9.5±1.7)
9. Various imaging modalities may be of use during clinical management, in addition to laboratory and clinical evidence (9.1±1.3)
10. After achievement, maintenance of the treatment target throughout the disease course is the optimal outcome (9.8±0.5)
11. Patient education and involvement are essential when discussing the treatment target, as well as any benefits and risks associated with the proposed therapeutic regimen (9.9±0.4)

As this is an area of continued research, the task force noted that further studies, both planned and in progress, will greatly aid in determining future directions for clinical practice, as well as future revisions to the current overarching principles and recommendations. 

They noted that these guidelines are very much about rigorous physician-patient interaction throughout the treatment process. In their conclusion, the researchers struck a hopeful tone, writing: “Adhering to these recommendations may significantly improve outcomes in patients with axial and peripheral SpA and PsA.”

Reference

Smolen JS, Schöls M, Braun J, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2017;77(1):3-17. doi:10.1136/annrheumdis-2017-211734