Understanding the Treat to Target Principle in Rheumatology

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"Treat to target" is a principle or approach that has been successful in treating certain diseases and conditions. The strategy initially was used to treat hypertension, high cholesterol, and diabetes. But, the scope has broadened and treat to target has made its way into the thinking of rheumatic disease specialists.

A treat to target strategy must have these three things:

  • a target
  • a way to measure if the target has been hit or achieved
  • available treatment options which make it possible to hit the target

With regard to hypertension, the targeted blood pressure reading is less than 150/100 mm Hg, with less than 140/90 being even more effective at reducing cardiovascular events. To achieve the desired goals for total cholesterol and LDL, statins are often prescribed. For patients with diabetes, there are clinical guidelines for blood glucose and hemoglobin A1C. What is considered the target in rheumatology?

Treat to Target in Rheumatoid Arthritis

In rheumatoid arthritis, the primary target is remission. Low disease activity is also another target, perhaps even more achievable and more realistic in many cases. To hit the target, inflammation must be controlled or suppressed. This is measured by evaluating disease activity. DAS28 (Disease Activity Score) or CDAI (Clinical Disease Activity Index) are among the ways disease activity can be assessed. The optimal frequency of disease activity monitoring has not been determined, but DAS28 less than 2.6 is generally considered to be indicative of remission in a rheumatoid arthritis patient.

Another important caveat not to be overlooked — treatment targets should be individualized. Comorbidities, history of adverse drug events, and which joints are affected should be taken into account when developing a target strategy.

Treat to Target in Lupus

An international task force has been developing a treat to target strategy for lupus as well. The task force established that remission of organ manifestations, as well as systemic symptoms of lupus, is a primary target of treatment for lupus. Another treat to target goal for lupus involves the prevention of flares, including nephritis, neuropsychiatric symptoms, and overall lupus symptoms. Prevention of damage also was established as a target, with the goal of preventing early and late organ damage by controlling disease activity and toxicity from medications. Attention paid to a patient's quality of life is also important. 

Going forward, the task force intends to develop definitions for lupus remission and minimally acceptable disease activity. There is also a need for better assessment of flares.

While there is hope for new lupus drugs in the future, there have been many more developed and marketed for rheumatoid arthritis since 1998 (when Enbrel became the first biologic drug approved for rheumatoid arthritis). Regarding drugs that are currently used to treat lupus, the task force will seek to determine if there is a low level of steroids that would be considered safe in a treat to target strategy. Also, questions about the appropriateness of hydroxychloroquine for all lupus patients still exist.  

Treat to Target for Spondyloarthritis

In 2013, an expert panel considered whether patients with spondyloarthritis could benefit from a treat to target approach. They concluded that treat to target could apply to spondyloarthritis but that guidance on how to define, measure or even achieve the goals of remission or inactive disease fall short in this disease category. Trials don't yet exist that specify quantifiable measures for disease activity in spondyloarthritis. Work needs to be done. For now, recommendations were made based on indirect evidence.

One study though, specific to psoriatic arthritis, compared a group of patients receiving standard care with methotrexate to another group who received more intensive care with the drug. According to Rheumatology News, the intensive group followed a strict protocol and if minimal disease activity criteria failed to be met, then the dose of methotrexate was escalated. Again, if patients failed to meet disease activity criteria, they were given a powerful combination of DMARDs. If they still didn't achieve the target, the intensive group was given a TNF blocker. Results showed that the intensive group did better than the standard group who remained on methotrexate without a plan for drug escalation or disease activity measurement.

Also, at the annual European Congress of Rheumatology, a 5-year extension of a randomized, controlled trial of Simponi (golimumab) in patients with psoriatic arthritis showed better long-term outcomes in patients able to achieve minimal disease activity through a treat to target approach.

The Bottom Line

Researchers conducted a systematic search of scientific literature with regard to treat to target in rheumatology. They concluded that "only few studies have used a randomized approach to test the value of treatment to a specific target. However, all of them provided compelling evidence of clinical benefits of such an approach. However, more data are needed concerning radiographic and functional outcomes and patients with longstanding RA [rheumatoid arthritis] have not been sufficiently investigated."

Theoretically, having specific treatment goals, especially achievable treatment goals, makes sense. To put this into practice, the targets or goals must become more well-defined for rheumatic diseases. 

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