New recommendations for treat-to-target in rheumatoid arthritis

Treating to target by measuring disease activity and regularly adjusting therapy results in the best outcomes for people with rheumatoid arthritis.

Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints and sometimes their internal organs, causing pain and disability. Treat-to-target is an important way of managing people with rheumatoid arthritis. Treating to target means setting a specific goal of remission (no or minimal inflammatory activity of rheumatoid arthritis) or low disease activity (low inflammatory activity) and then tailoring a person’s treatment to help them reach that goal. Remission and low disease activity are measured using a variety of clinical tests and monitoring the patient’s symptoms. Recommendations help doctors to treat patients with specific diseases. Recommendations on treating to target in rheumatoid arthritis were first published in 2010.

The authors wanted to look for new evidence that could be included in an update of the treat-to-target recommendations.

The authors looked at studies that had already been published. These all reported the use of treat-to-target strategies in people with rheumatoid arthritis.

This study was based on a systematic review, which aims to identify all the published evidence on a particular topic and draw it together into one summary. The authors used electronic databases to search for trials and studies that reported studies of treat-to-target strategies in people with rheumatoid arthritis published since the last recommendations in 2010. The search gave a long list of 176 articles. Of these, 6 had the correct type of information and were included in the review. Once the results were collected a committee of physicians and patients met to discuss and vote on the information that should be included in the updated recommendations, and how to reword and order the original 2010 recommendations.

The new recommendations are based on a set of four main ideas or ‘overarching principles’. Treatment of rheumatoid arthritis should be based on a shared decision between a patient and their doctor. The goal of treating people with rheumatoid arthritis is to improve their well-being over a long period and help them to be able to take part in work and social activities. Inflammation leads to pain, swelling and damage in the joints, and can cause disability. Stopping inflammation is the most important way to achieve treatment goals, and treating to target ensures the best outcomes for patients.

There are 10 recommendations:
1. The main target for people with rheumatoid arthritis should be remission.
2. Remission is an absence of signs and symptoms of inflammatory disease.
3. Low disease activity may be an alternative goal for people who have had the disease for a very long time.
4. Doctors should use standard measurements to monitor the disease activity.
5. Which measure doctors use might depend on what other illnesses a patient has and what other medicines they are taking.
6. Disease activity should be measured and recorded frequently.
7. Structural changes in a joint (those seen on an X-ray), other illnesses and a person’s inability to use a joint should be taken into account when deciding how to treat.
8. Medicines should be adjusted every 3 months until the target is reached.
9. The treatment target should be maintained.
10. Patients should be involved in setting the target and deciding on the course of action.

Targeting low disease activity or remission in people who have had rheumatoid arthritis for a long time is now seen as a strong goal because there is new data about how well treatment works. Whether people have other diseases (comorbidities) is important in choosing the right treatment and dose. Regular monitoring of whether the disease has progressed (got worse) is important, and this can be done using imaging techniques such as X-ray, ultrasound or MRI (magnetic resonance imaging) to get a picture of the inside of the joint and any damage that has occurred.

These findings are based on evidence that has already been published elsewhere, but they are new in that they expand on and update the old version of the recommendations.

There are some gaps in the recommendations. For example, the authors could not find any practical information about how to implement treat-to-target in normal clinics.

These recommendations will be shared with doctors and other health professionals working with people with rheumatic diseases. It is hoped that many doctors will use them when treating their rheumatoid arthritis patients.

If you have rheumatoid arthritis, these new recommendations could mean that your doctor will change the way you are treated. You may already have a treat-to-target goal, but if not your doctor may discuss this with you. It is important that the treat-to-target strategy should be based on shared decision between you and your doctor. If you have any questions about your treatment and how these new recommendations might affect you, you should speak to your doctor.

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Date prepared: February 2016

Summary based on research article published on: 12 May 2015

From: Smolen, JS. et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 2016;75:3–15. doi: 10.1136/annrheumdis-2015-207524.

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