Target To Treat For Rheumatoid Arthritis

Goals, Obstacles, Practice, and Your Role

Rheumatoid arthritis (RA) is a chronic autoimmune disease that has kept doctors and their patients on their toes for decades, and especially as they continue to figure out the best ways to manage disease symptoms and slow down disease progression. Fortunately, recent advances in treatment strategies and medications have brought about positive health outcomes and improved quality of life for many with RA. Doctors and researchers know now keeping RA under control is much easier when goals are set and progress is monitored closely—a concept in RA treatment called target to target (TTT).

In TTT, special disease management goals are set, and activity is measured frequently. When targets are not reached, new goals are set. The process continues until the target goal has been achieved.

History and Goals of TTT

In 2010, an Austrian rheumatologist Josef Smolen, M.D. introduced 10 recommendations for optimizing RA care. These were based on the idea that choosing a target goal—low disease activity or clinical remission­—and then aggressively pursuing that goal with medications and frequent investigation of disease activity. Disease activity measurements are an important part of TTT because, in order to treat someone and determine if treatment is effective, you need to be able to measure progress.

With RA, the main goal is either remission or low disease activity. Remission in RA means that the disease is no longer active. A person may experience an occasional flare-up every now and then, which symptoms are managed, but not completely gone. The low disease activity goal gets as close to remission as possible.

To hit the target of remission or low disease activity, inflammation is controlled and/suppressed. Your doctor determines your progress by using a disease activity score (DAS28). Optimal disease activity numbers for TTT have not been determined but a DAS28 less than 2.6 is generally a sign of remission. Low disease activity falls close to a 2.6 score.

Another important aspect feature of TTT is that treatment can be individualized. This way comorbidities (where another chronic condition co-exists with RA), previous treatment history, and affected joints are all considered when planning and implementing a targeted strategy.

Obstacles in TTT

TTT recommendations were initially presented to create a standardized approach to treating RA in both the short and long term. However, not everyone is and has been on board with the practice.

Rheumatologists

A survey reported in 2013 of 1,901 rheumatologists from 34 countries asked rheumatologists about the level of agreement with TTT recommendations. Many agreed with TTT strategies and some indicated they were implementing these in their practices. However, a substantial number shared they were not applying the new strategy for treating RA.

In 2014 and in response to the lack of TTT practice, Josef Smolen and a team of researchers updated target to target strategies in hopes of getting the medical community on board. At that time, the task force suggested setting a treatment goal of remission or low disease activity, seeing patients every 1 to 3 months, and switching therapies as often as necessary to achieve the target goal. Tracking improvements became more aggressive and required consistent measurements and recording of disease activity.

Smolen’s team also emphasized TTT as a shared decision-making effort between the patient and their doctor. However, the 2014 update did not give any guidance as to where disease activity measurements should be or what treatment should look.

In 2016, the American College of Rheumatology (ACR) endorsed TTT but did not put a requirement on rheumatologists to practice the strategy. With the ACR's endorsement and research in favor of TTT, many rheumatologists are now utilizing TTT as a standard practice in managing RA.

Relectuance From People Living with RA

Doctors are not the only ones with reluctance towards TTT. People with RA must be willing to change medications often and come in for appointments and testing often. Additionally, some may feel switching medications frequently does not offer much benefit, especially if they have had RA for many years. Another deterrent for people with RA includes not feeling sick enough to want to try a new approach, especially over a short period.

A survey reported in 2017 involved interviewing 48 people with RA about their experiences using disease-modifying antirheumatic drugs (DMARDs) and feelings that push compliance or resistance to treatment. Researchers found two themes that existed when people with RA adhered to treatment—the desire to return a normal life and the fear of disability in the future.

With treatment resistance, five themes emerged:

1.   Fear of medications

2.   Needing to feel in control of their own life and health

3.   Not waiting to identify as sick

4.   Disappointment with treatment

5.   Feeling overwhelmed with treatment decisions

The researchers note these findings confirm the importance of involving the RA patient in the TTT process. For some people, this process can be scary, especially when you have had RA for a long time. Medication changes are especially hard because side effects medications—big or small—are something no one wants to deal with.

Medication Access

A continuing obstacle in TTT is access to treatments. TTT requires medication changes over a short period. With active disease, delays are not realistic if TTT is to be successful. But gaining approval for expensive RA drugs is not quick and it can be a long process. In addition, expensive drug costs, insurance pre-approvals, and high co-pays add to the burden of inaccessibility to treatments.

TTT in Practice

In the past, rheumatologists treated people with RA by adjusting their medications based on the doctor’s own clinical judgment. With these older practices, testing was less frequent although improvements are similarly based on disease activity scores. Remission and low disease activity were hoped for, but not emphasized.

In contrast, the TTT approach can lead to long-term remission in people who treat early for RA. It is also an effective tool for treating people who have had RA for many years. And over the past 10 years, numerous randomized controlled studies have shown the TTT strategy shows superior treatment outcomes—this in comparison to previous practices.

Early RA

Studies have shown TTT is effective in treating people with early RA. In one large Dutch study reported in 2019, researchers determined remission was very achievable in people who had RA for less than a year while using TTT. Additionally, 43 percent of the 342 study participants were still experiencing remission after 3 years.

The study’s treatment protocol involved the use of classic DMARDs as an initial treatment, which included 15 milligrams (mg) of methotrexate that was raised to 25 mg in people who did not respond well. Another DMARD, sulfasalazine, was added after 12 weeks where there wasn't sufficient improvement. For the study participants who were not showing improvements by the 6-month mark, sulfasalazine was replaced with a TNF-inhibitor biologic.

Interestingly, most of the study participants only needed traditional DMARDs (methotrexate and/or sulfasalazine) with TTT. These results indicate treatment with TTT in early RA can be successful with methotrexate alone or by using methotrexate with another traditional DMARD.

Longstanding RA

A long-standing disease is one that has lasted 6 months or more and is likely to last for a person’s entire life. In fact, the main characteristics of a long-standing health condition are permanency and the need for long-term monitoring and care. When used to describe RA, long-standing disease refers to a condition that has existed for a long time.

In a 2013 study reported by Arthritis Care & Research, researchers found TTT was an effective strategy for treating people with long-standing RA. The Canadian study enrolled 308 people with long-standing, active RA that were randomized into several groups, with two of those using TTT. The TTT groups were able to achieve remission more quickly than the routine care groups. Additionally, they were less likely to leave the study.

The results of the 2013 study suggest even with long-standing RA treated with a specific biologic therapy, people with RA can achieve low disease states faster. They are also more likely to adhere to treatment if their doctors are targeting a treatment rather than using routine care.

Sustained TTT

A study reported in 2020 finds when TTT is correctly put into place, disease outcomes are extremely positive. The study included 571 patients with RA who were treated by their own rheumatologist. The TTT strategy was used over a 2-year period where the patients were assessed every three months. The main goal was low disease activity or remission.

The researchers determined when TTT was applied correctly and sustained, rates for remission were high. The TTT strategy was continued at 59 percent of follow-up visits. After 3 months, 24 percent of the patients were in remission, and at 2 years, 52 percent were still in remission.

What This Means for You

Your doctor relies on various assessment methods to measure remission and low disease activity. This includes a physical exam to determine the number of swollen and tender joints, bloodwork measuring inflammation levels, and information from you on about your pain and function levels. Your score—based on a tracking system called the DAS-28—determines the level of disease activity you have with RA.

DAS-28 disease activity is based on the number of swollen and joints, bloodwork, and your overall assessment of pain, other symptoms including fatigue, and level of function using a mathematical formula. That formula generates a score range from 2 to 10.

DAS-28 disease activity score ranges are:

  • Remission—Less than 2.6
  • Low disease activity—Between 2.6 and 3.2
  • Moderate disease activity—Between 3.3 and 5.1
  • High disease activity—Higher than 5.1

In determining disease activity and TTT success, your doctor isn’t the only one who has a part to play. You help by reporting necessary information, being patient, and working towards your long-term health.

Reporting

Your main role in TTT care is to report to your doctor how RA pain and symptoms affect your ability to function in your daily life. Your doctor will want to know if you have experienced new difficulties, such as with getting dressed and managing household tasks. You may want to share how you are functioning both at work and at home, how tired you are feeling throughout the day, and if certain activities bring about disease flares.

Your doctor has set goals for you and wants to know if you are achieving them, how you are tolerating medications, and if you have problems taking medications or getting access to medications. Once you have reached your target goal, your doctor will continue to work with you to help your life to resemble some sense of normal where you don’t experience high levels of pain and swelling.

Patience

Your role doesn’t stop being important after you achieve low disease activity or remission. Even though you have achieved your TTT goal, your treatment plan won’t change right away. This is because your doctor doesn’t yet know what will happen if medications are adjusted or stopped.

Before tapering medication or stopping a treatment, your doctor will want you experiencing low disease activity or remission for several months. Unfortunately, there isn’t enough research that predicts who will do well and who will experience flare-ups if medications are tapered down or changed. This a trial and error process that is uniquely tailored towards your lifestyle and overall health.

Your doctor is in the best position to decide when it is time to taper down medication doses. You should never stop taking RA medications without your doctor’s approval regardless of how well you are feeling.

Long-Term Health

In addition to feeling better, your doctor will want to determine if you’re continuing to meet your goal and how your overall health might be going forward. Tight control of your disease helps your doctor continue to measure disease progression and ultimately results in improved long-term function.

You should continue to be open with your rheumatologist about function and pain levels, as well as the side effects of medications. Through an ongoing team effort, the two of you can make continuous adjustments to your RA treatment plan that put on you the path to sustained remission or low disease activity, and a healthier future.

A Word From Verywell

Doctors and researchers believe TTT is effective because it pushes doctors to test more and to be aggressive in altering treatment when one therapy isn’t working. It is also helpful for both people with RA and their doctors to have a specific goal in mind. For many people with RA, this course of action can be meaningful and motivate them to stay on top of their treatment.

There is no question that RA is challenging to manage and live with. But thanks to aggressive treatment strategies and newer, more powerful therapies, outcomes for people with RA can positive. If your rheumatologist hasn’t brought TTT to your attention or is using an older treatment practice, talk to them about your treatment options and what you would like to accomplish from TTT. It may take time to find the approach that gets you to remission or low disease activity, so stay focused and continue working with your doctor until your treatment goal is met. 

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