Editorial
Treating rheumatoid arthritis to target: Evidence-based recommendations for enhanced disease management
Tratamiento certero de la artritis reumatoide: recomendaciones basadas en la evidencia para un mejor tratamiento de la enfermedad
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Smolen" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Monika" "apellidos" => "Schoels" "email" => array:1 [ 0 => "monika.schoels@live.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Josef S." "apellidos" => "Smolen" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "2nd Department of Internal Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Austria" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento certero de la artritis reumatoide: recomendaciones basadas en la evidencia para un mejor tratamiento de la enfermedad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The approach to managing rheumatoid arthritis (RA) is still variable. Questions or issues that frequently arise relating to the application of types and sequences of therapeutic agents as well as to the extent and frequencies of follow up examinations, types of assessments and needs for therapeutic adaptations. In light of these occasional ambiguities, recommendations for the management of rheumatoid arthritis have been recently published.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition, an international expert committee elaborated a guideline document adopting a “treat to target” (T2T) approach for RA; in line with the presentation of the T2T strategy, detailed standard procedures were provided to enable its implementation into daily clinical practice by the rheumatology community.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While the definition of quantifiable treatment targets is new to RA management, stringent therapeutic aims have already been implemented in a number of other chronic diseases: in diabetes care, aiming for an HbA1c below 7.0% is widely recognized to be the task in every counseling visit, since the achievement of this threshold is understood to drive long-term disease outcomes. Similar procedures are used in treating hypertension, hyperlipidemia, and other conditions, as opposed to the avoidance of adverse outcomes in the distant future; an absolute number that displays a level of good disease control, or, if unmet, the need for treatment escalation is well perceived by doctors and patients alike. Presumably, this facilitates shared treatment decision-making, and also encourages patients to be adherent and responsive during their chronic condition.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The adoption of T2T for RA has been initiated by an international task force of 20 experts in rheumatology and a patient with RA, who first convened in 2008. As an initial step, the group performed a systematic literature review (SLR) to compile all published evidence on targeted treatment in RA, when compared to standard care.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the systematic literature search, 5881 titles and abstracts were identified in electronic databases resulting in 76 articles selected for full text inspection. Finally, 7 studies that provided direct evidence on targeted treatment were included in the review.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–10</span></a> While the data was scarce for long-standing disease,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> available evidence unanimously substantiated the benefit of targeted treatment in early RA (ERA).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> Strategy-driven arms showed significantly better outcomes in all trials, when disease activity was taken into account. One study also reported better functional outcomes.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Five trials investigated radiographic endpoints, three of them showed significant benefits in the targeted treatment arm.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In particular, the interval to schedule follow-up visits and ascertain response to therapy, as well as the definition of therapeutic success by specification of treatment targets were backed by a body of evidence from the literature: all ERA trials adopted follow-up intervals of between one and three months in their targeted treatment arms,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–9</span></a> and for long-standing disease, four months was chosen to be the maximum interval for re-assessment.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Therapy had to be amended, if targeted disease activity thresholds were not met within this period. The targets were in remission or at least had low disease activity (LDA) and some trials also adopted a set of individual targets like combined laboratory and joint count thresholds.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This systematic search on available information served as a basis for subsequent discussions among the steering committee to formulate an initial set of T2T recommendations for RA disease management. Inviting a broader panel of more than 60 international rheumatologists and several additional RA patients, including participants from Europe, North and Latin America, Japan and Australia, the steering committee presented a draft document for further discussion and refining during a Delphi-like process in March 2009. The final document<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that originated from this complex consensus-finding process provides guidance for routine outpatient care. It comprises 4 overarching principles and 10 recommendations.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Along with anchoring every treatment change to a shared decision between patient and doctor, the core statement of this document is the postulated necessity for further adjustment of therapy at every follow-up visit until the therapeutic target is reached. This approach is particularly applicable for newly diagnosed RA, but also has to be maintained throughout the whole course of disease. Importantly, treatment success has to be ascertained at least every 3 months, and an increased frequency of visits is suggested if patients show high or moderate disease activity. Patients in sustained remission (or LDA) should be seen by a specialist about every 6–12 months to document continuous sufficient disease control by obtaining composite disease activity scores that include joint counts. The advocated treatment target is remission, defined as the absence of signs and symptoms of significant inflammatory disease activity. Achieving remission is stated to be of paramount importance in ERA, however in longstanding disease that has proven to be refractory, low disease activity (LDA) may be an acceptable alternative target. In addition to ensuring successful suppression of inflammation by validated compound disease activity indices, the consideration of structural damage and functional limitation in all treatment decisions is strongly emphasized. Also, co-morbidities, and other individual patient-related factors, as well as drug-related risks should be taken into account.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Notably, this call for targeted treatment is devoid of any particular drug recommendation or any preference for specific treatment escalation approaches, like adding-on drugs versus switching, etc. Rather, the T2T guidance document defines the therapeutic goal to strive for and establishes standard procedures to ensure ideal utilization of all available drugs. Details can be accessed via the references provided here.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Most experts recognize that consistent suppression of disease activity is linked to better functional and radiographic outcomes. Rheumatologists have a growing number of synthetic and biologic disease modifying drugs at hand, yet rapid change of therapy, if needed, has not been fostered in treatment guidelines. According to the SLR, unanimous evidence speaks in favor of strategic targeted treatment adjustment to reach a satisfying disease control. The broad consensus among the international rheumatologists’ community in the process of developing this set of recommendations will hopefully result in a widespread adoption of T2T in clinical practice and contribute to optimized RA care.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-07" "fechaAceptado" => "2011-07-13" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Schoels M, Smolen JS. Treating rheumatoid arthritis to target: Evidence-based recommendations for enhanced disease management. Reumatol Clin. 2011. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2011.07.002">doi:10.1016/j.reuma.2011.07.002</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.S. Smolen" 1 => "R. Landewe" 2 => "F.C. Breedveld" 3 => "M. Dougados" 4 => "P. Emery" 5 => "C. 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Scott" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Health Technol Assess" "fecha" => "2005" "volumen" => "9" "paginaInicial" => "1" "paginaFinal" => "78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16303099" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000800000001/v1_201305061634/S2173574311000803/v1_201305061634/en/main.assets" "Apartado" => array:4 [ "identificador" => "17335" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000001/v1_201305061634/S2173574311000803/v1_201305061634/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574311000803?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 11 | 22 |
| 2024 October | 26 | 25 | 51 |
| 2024 September | 30 | 34 | 64 |
| 2024 August | 50 | 39 | 89 |
| 2024 July | 31 | 30 | 61 |
| 2024 June | 28 | 26 | 54 |
| 2024 May | 46 | 29 | 75 |
| 2024 April | 29 | 20 | 49 |
| 2024 March | 40 | 36 | 76 |
| 2024 February | 26 | 29 | 55 |
| 2024 January | 25 | 18 | 43 |
| 2023 December | 22 | 25 | 47 |
| 2023 November | 30 | 28 | 58 |
| 2023 October | 43 | 33 | 76 |
| 2023 September | 64 | 37 | 101 |
| 2023 August | 23 | 21 | 44 |
| 2023 July | 27 | 23 | 50 |
| 2023 June | 22 | 26 | 48 |
| 2023 May | 35 | 26 | 61 |
| 2023 April | 31 | 9 | 40 |
| 2023 March | 45 | 19 | 64 |
| 2023 February | 40 | 27 | 67 |
| 2023 January | 33 | 35 | 68 |
| 2022 December | 39 | 49 | 88 |
| 2022 November | 43 | 43 | 86 |
| 2022 October | 41 | 36 | 77 |
| 2022 September | 38 | 33 | 71 |
| 2022 August | 32 | 37 | 69 |
| 2022 July | 33 | 39 | 72 |
| 2022 June | 22 | 31 | 53 |
| 2022 May | 30 | 45 | 75 |
| 2022 April | 43 | 47 | 90 |
| 2022 March | 48 | 51 | 99 |
| 2022 February | 36 | 49 | 85 |
| 2022 January | 39 | 43 | 82 |
| 2021 December | 37 | 32 | 69 |
| 2021 November | 45 | 41 | 86 |
| 2021 October | 43 | 62 | 105 |
| 2021 September | 32 | 42 | 74 |
| 2021 August | 27 | 40 | 67 |
| 2021 July | 17 | 26 | 43 |
| 2021 June | 28 | 40 | 68 |
| 2021 May | 39 | 51 | 90 |
| 2021 April | 68 | 90 | 158 |
| 2021 March | 43 | 37 | 80 |
| 2021 February | 33 | 14 | 47 |
| 2021 January | 23 | 23 | 46 |
| 2020 December | 40 | 22 | 62 |
| 2020 November | 11 | 20 | 31 |
| 2020 October | 16 | 13 | 29 |
| 2020 September | 23 | 18 | 41 |
| 2020 August | 26 | 18 | 44 |
| 2020 July | 25 | 20 | 45 |
| 2020 June | 33 | 32 | 65 |
| 2020 May | 34 | 10 | 44 |
| 2020 April | 44 | 18 | 62 |
| 2020 March | 17 | 9 | 26 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 0 | 2 | 2 |
| 2019 August | 0 | 1 | 1 |
| 2019 May | 0 | 1 | 1 |
| 2019 April | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 59 | 13 | 72 |
| 2018 March | 62 | 22 | 84 |
| 2018 February | 40 | 5 | 45 |
| 2018 January | 38 | 8 | 46 |
| 2017 December | 35 | 7 | 42 |
| 2017 November | 40 | 8 | 48 |
| 2017 October | 37 | 10 | 47 |
| 2017 September | 35 | 7 | 42 |
| 2017 August | 49 | 23 | 72 |
| 2017 July | 43 | 20 | 63 |
| 2017 June | 74 | 45 | 119 |
| 2017 May | 87 | 21 | 108 |
| 2017 April | 68 | 21 | 89 |
| 2017 March | 73 | 16 | 89 |
| 2017 February | 51 | 10 | 61 |
| 2017 January | 51 | 12 | 63 |
| 2016 December | 88 | 22 | 110 |
| 2016 November | 66 | 12 | 78 |
| 2016 October | 89 | 19 | 108 |
| 2016 September | 82 | 8 | 90 |
| 2016 August | 77 | 6 | 83 |
| 2016 July | 40 | 7 | 47 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 0 | 4 | 4 |
| 2016 April | 0 | 9 | 9 |
| 2016 March | 0 | 8 | 8 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 0 | 9 | 9 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 16 | 8 | 24 |
| 2015 June | 31 | 6 | 37 |
| 2015 May | 41 | 9 | 50 |
| 2015 April | 28 | 9 | 37 |
| 2015 March | 31 | 8 | 39 |
| 2015 February | 31 | 11 | 42 |
| 2015 January | 28 | 16 | 44 |
| 2014 December | 33 | 7 | 40 |
| 2014 November | 26 | 12 | 38 |
| 2014 October | 24 | 14 | 38 |
| 2014 September | 28 | 14 | 42 |
| 2014 August | 21 | 20 | 41 |
| 2014 July | 33 | 19 | 52 |
| 2014 June | 47 | 14 | 61 |
| 2014 May | 21 | 22 | 43 |
| 2014 April | 35 | 13 | 48 |
| 2014 March | 29 | 21 | 50 |
| 2014 February | 26 | 13 | 39 |
| 2014 January | 25 | 26 | 51 |
| 2013 December | 26 | 11 | 37 |
| 2013 November | 28 | 12 | 40 |
| 2013 October | 29 | 21 | 50 |
| 2013 September | 34 | 21 | 55 |
| 2013 August | 37 | 18 | 55 |
| 2013 July | 21 | 13 | 34 |
| 2013 June | 26 | 19 | 45 |
| 2013 May | 26 | 17 | 43 |
| 2013 April | 27 | 27 | 54 |
| 2013 March | 25 | 27 | 52 |
| 2013 February | 18 | 15 | 33 |
| 2013 January | 14 | 23 | 37 |
| 2012 December | 21 | 22 | 43 |
| 2012 November | 27 | 37 | 64 |
| 2012 October | 14 | 33 | 47 |
| 2012 September | 6 | 2 | 8 |
| 2012 July | 2 | 0 | 2 |
| 2012 June | 3 | 0 | 3 |
| 2012 May | 4 | 0 | 4 |
| 2012 April | 2 | 0 | 2 |
| 2012 March | 7 | 0 | 7 |
| 2012 February | 5 | 0 | 5 |
Show all
