Treat to Target Approach Improves RA Outcomes
When doctors “treat to target” – with specific goals – patients improve faster and stick with meds.
As with most any endeavor in life, treating rheumatoid arthritis (RA) is more likely to be successful when you set goals and monitor your progress toward them, a concept known in medicine as treat to target (T2T).
T2T is a medical strategy that sets remission – defined as the absence of signs and symptoms of significant inflammatory disease activity -- or, at the very least, low disease activity as a goal. Disease activity is measured as frequently as monthly for patients with high/moderate disease activity through lab tests and clinical examinations. If the target is not reached, medications and doses are immediately adjusted according to a predefined protocol. The process continues until the goal is achieved.
T2T vs. Routine Care for Early RA
In the traditional way of treating RA, known as routine care, physicians adjust medications according to their own clinical judgment. Testing is generally less frequent, treatment is often less aggressive, and an improvement of a specific percentage such as 50 or 70 percent (ACR50 or ACR70) is often considered a success.
A number of studies have shown that the treat-to-target approach is effective in patients with early RA. In the largest of these, a Dutch study called the Dutch Rheumatoid Arthritis Monitoring (DREAM) trial, researchers found that remission was not only an achievable goal for patients with symptom duration of one year or less using the T2T approach, but that for almost half – 43 percent of 342 patients – was sustained at three-year follow-up. Those findings were published in 2013 in Arthritis Care & Research.
“Our study showed that T2T results in low disease activity and high [sustained] remission rates, improved physical function, better health-related quality of life and limited radiographic damage, which sustain over three years,” says Marloes Vermeer, who led the study as a PhD student at the Arthritis Centre Twente, University of Twente, Enschede, The Netherlands.
The drug protocol in the study called for conventional disease-modifying anti-rheumatic drugs (DMARDs) as initial treatment, starting with a weekly 15-milligram dose of methotrexate, which was raised to 25 milligrams in poor responders. Sulfasalazine was added after 12 weeks, if necessary. For those still not responding at six months, an anti-TNF biologic agent, such as adalimumab (Humira), replaced the sulfasalazine.
But, Vermeer says, the majority of patients needed only the conventional drugs. “Our study shows that methotrexate monotherapy, followed by combined treatment with other DMARDs, when indicated, is highly successful in achieving the treatment goal of remission, Vermeer says.
T2T for Longstanding RA
In a separate study published the same year in Arthritis Care & Research, Canadian researchers found that T2T is effective for people with longstanding RA as well. In Optimization of Adalimumab Randomized Trial (OART), which enrolled 308 patients with established, active RA, participants randomized to two T2T groups not only achieved remission more quickly than a routine care group, but they were also less likely to drop out of the study.
The trial was the first to show that “even in established RA treated with a specific biologic agent, patients will get into a low disease state faster and are more likely to remain on their biologic drug if doctors are treating to a target rather than performing usual care,” says lead study author Janet Pope, MD, professor of medicine and chair of the division of rheumatology with the University of Western Ontario Schulich School of Medicine & Dentistry, in Canada.
Dr. Pope says it is possible that doctors who treat to a specific target may make more changes in the therapies the patient is taking, whereas doctors who provide routine care may not make as many. These adjustments are what may lead to improved outcomes. Stanley B. Cohen, MD, a clinical professor in the department of internal medicine at the University of Texas Southwestern Medical School in Dallas, who was not involved in the study, says treating to target is “the wave of the future rheumatology.”