Rheumatologists should follow a T2T-strategy in patients with both early and established rheumatoid arthritis.
Introduction
Rheumatoid arthritis is a chronic inflammatory disease that can affect a person’s joints, and may cause pain and disability. Rheumatoid arthritis affects people of all ages, and is more common in women than men.
‘Treat to target’ (often shortened to T2T) has worked well in clinical trials in people with rheumatoid arthritis. When a doctor tries to treat to target, they start by setting a goal. This is often remission – meaning you have no signs or symptoms of active disease. They then closely monitor your disease activity, and adjust treatment according to a set of rules to help you get to the goal. T2T has been tested in clinical trials. Clinical trials are good at finding out specific things, but in real life people are more complicated – and doctors may have less time or resources than in a trial. Clinical trials often exclude people with certain types of disease or treatment history, but in real life it is important to be able to treat everybody.
What did the authors hope to find?
The authors looked at T2T in real life to see how well it is being followed. They wanted to see how well it works in real life, and whether people who follow T2T achieve remission more often than people who are not on T2T. The authors also wanted to know whether T2T works in people with established rheumatoid arthritis,
not just those who are newly diagnosed.
Who was studied?
The study looked at 571 people with rheumatoid arthritis who had taken part in the RA BIODAM study. People were being treated in clinics across 10 countries. Everyone had active disease, and was about to be started on – or change to – a conventional DMARD medicine or a biologic medicine called a TNF inhibitor. People could
not take part if they had tried a biologic medicine before.
How was the study conducted?
This was a longitudinal observational study, which means that the researchers simply observed people in normal clinics and recorded information at several time points. People visited the clinic once every 3 months and had their disease activity measured, and notes made about the treatment they were on. The aim of therapy was
remission. The authors looked at people’s clinical notes to see whether the doctors had followed the T2T strategy properly. This was measured based on whether people’s treatment had been changed at the right time according to their disease activity score. If T2T was properly followed in at least two consecutive visits, this was defined as ‘sustained T2T’. The authors then looked to see if there was a relationship between following T2T at a clinic check-up, and meeting the target goal of remission at the next visit 3 months later.
What were the main findings of the study?
The main finding was that a T2T-strategy led to more people achieving the goal of remission. There was evidence that following T2T – and especially sustained T2T – made it more likely that a person would be in remission at the next visit, 3 months later.
Are these findings new?
Yes, this is the first study to look in detail at all available visits of real-life T2T patients over 2 years. It is also the first time that T2T has been shown to work in people with established RA.
What are the limitations of the study?
There are some limitations. First, the patient information came from RA BIODAM, which was set up in specialist centres, where the doctors were following a set T2T programme. This might not reflect normal everyday practice for people seen in general rheumatology clinics. Also, where doctors were not following T2T, there were not always notes to explain why. There could have been good medical reasons for choosing a different approach, or it could have been the patient’s decision not to change treatment at a particular point. Finally, only people with active disease were included, and the disease activity at the start of the study was high. This means the findings might not apply to people with low disease activity, and so it is not possible to say whether following a T2T-strategy is beneficial for people who are already in low disease activity, or if there is a risk of over-treatment.
What do the authors plan on doing with this information?
This information will be shared with rheumatologists and patients. Doctors should be encouraged to follow a T2T-strategy to help get people to remission, but it is important to properly assess disease activity and use the information to make treatment decisions.
The authors are planning a follow-up study to see whether following a T2T-strategy helps inhibit joint damage, as seen on an X-ray.
What does this mean for me?
If you have rheumatoid arthritis, using a treat-to-target strategy with your doctor will lead to better outcomes. It is important that your disease activity is measured often, and that you talk to your doctor about the results and any treatment changes you need. Being engaged in the management of your disease, and understanding the benefits of treat-to-target, will help you look after yourself better.
If you have any concerns about your disease or its treatment, you should talk to your doctor. It is important that you do not stop taking any medicine you have been prescribed without getting proper medical advice.
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Date prepared: March 2020
Summary based on research article published on: 24 February 2020
From: Ramiro S, et al. Is treat-to-target really working in rheumatoid arthritis? A longitudinal analysis of a cohort of patients treated in daily practice (RA BIODAM). Ann Rheum Dis 2020;79:453–459. doi:10.1136/annrheumdis-2019-216819
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