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 relate to the application of types and sequences of therapeutic agents as well as to the extent and frequencies of control 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 guidance document adopting a “treat to target” (T2T) approach for RA; in line with a respective presentation of the T2T strategy, detailed standard procedures were provided to enable the 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 at center stage 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 proceedings are used in treating hypertension, hyperlipidemia, and other conditions, as opposed to the formulation of adverse outcomes to avoid in the distant future, an absolute number that displays the level of good disease control, or, if not met indicates the need for treatment escalation, is well perceivable for 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 assigned 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 process of the systematic literature search, the screening of 5881 titles and abstracts identified in electronic databases resulted in 76 articles for fulltext 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 were 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">Especially 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 between one and three months in their targeted treatment arms,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–9</span></a> and in long-standing disease four months were 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 remission or at least low disease activity (LDA), 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 be 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 are in 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 had proved 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 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 "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. 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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" => "/1699258X/0000000800000001/v1_201305061912/S1699258X11002506/v1_201305061912/en/main.assets" "Apartado" => array:4 [ "identificador" => "17498" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/1699258X/0000000800000001/v1_201305061912/S1699258X11002506/v1_201305061912/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X11002506?idApp=UINPBA00004M" ]
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|---|---|---|---|
| 2024 Noviembre | 9 | 15 | 24 |
| 2024 Octubre | 40 | 28 | 68 |
| 2024 Septiembre | 43 | 15 | 58 |
| 2024 Agosto | 50 | 36 | 86 |
| 2024 Julio | 57 | 28 | 85 |
| 2024 Junio | 53 | 38 | 91 |
| 2024 Mayo | 46 | 25 | 71 |
| 2024 Abril | 48 | 29 | 77 |
| 2024 Marzo | 49 | 29 | 78 |
| 2024 Febrero | 49 | 28 | 77 |
| 2024 Enero | 39 | 23 | 62 |
| 2023 Diciembre | 43 | 28 | 71 |
| 2023 Noviembre | 31 | 24 | 55 |
| 2023 Octubre | 45 | 38 | 83 |
| 2023 Septiembre | 49 | 42 | 91 |
| 2023 Agosto | 45 | 13 | 58 |
| 2023 Julio | 42 | 25 | 67 |
| 2023 Junio | 29 | 25 | 54 |
| 2023 Mayo | 30 | 17 | 47 |
| 2023 Abril | 27 | 12 | 39 |
| 2023 Marzo | 42 | 37 | 79 |
| 2023 Febrero | 45 | 30 | 75 |
| 2023 Enero | 33 | 21 | 54 |
| 2022 Diciembre | 58 | 44 | 102 |
| 2022 Noviembre | 48 | 36 | 84 |
| 2022 Octubre | 55 | 30 | 85 |
| 2022 Septiembre | 39 | 34 | 73 |
| 2022 Agosto | 41 | 52 | 93 |
| 2022 Julio | 47 | 49 | 96 |
| 2022 Junio | 42 | 42 | 84 |
| 2022 Mayo | 36 | 44 | 80 |
| 2022 Abril | 53 | 52 | 105 |
| 2022 Marzo | 50 | 39 | 89 |
| 2022 Febrero | 51 | 33 | 84 |
| 2022 Enero | 50 | 42 | 92 |
| 2021 Diciembre | 34 | 49 | 83 |
| 2021 Noviembre | 55 | 45 | 100 |
| 2021 Octubre | 58 | 52 | 110 |
| 2021 Septiembre | 49 | 49 | 98 |
| 2021 Agosto | 29 | 32 | 61 |
| 2021 Julio | 32 | 29 | 61 |
| 2021 Junio | 45 | 47 | 92 |
| 2021 Mayo | 68 | 45 | 113 |
| 2021 Abril | 142 | 67 | 209 |
| 2021 Marzo | 87 | 39 | 126 |
| 2021 Febrero | 61 | 28 | 89 |
| 2021 Enero | 54 | 32 | 86 |
| 2020 Diciembre | 43 | 23 | 66 |
| 2020 Noviembre | 30 | 31 | 61 |
| 2020 Octubre | 22 | 20 | 42 |
| 2020 Septiembre | 45 | 28 | 73 |
| 2020 Agosto | 24 | 23 | 47 |
| 2020 Julio | 35 | 13 | 48 |
| 2020 Junio | 47 | 29 | 76 |
| 2020 Mayo | 41 | 21 | 62 |
| 2020 Abril | 31 | 25 | 56 |
| 2020 Marzo | 31 | 20 | 51 |
| 2020 Febrero | 53 | 24 | 77 |
| 2020 Enero | 30 | 27 | 57 |
| 2019 Diciembre | 38 | 47 | 85 |
| 2019 Noviembre | 16 | 22 | 38 |
| 2019 Octubre | 29 | 26 | 55 |
| 2019 Septiembre | 32 | 42 | 74 |
| 2019 Agosto | 30 | 30 | 60 |
| 2019 Julio | 25 | 25 | 50 |
| 2019 Junio | 11 | 35 | 46 |
| 2019 Mayo | 34 | 116 | 150 |
| 2019 Abril | 40 | 75 | 115 |
| 2019 Marzo | 22 | 34 | 56 |
| 2019 Febrero | 22 | 38 | 60 |
| 2019 Enero | 20 | 33 | 53 |
| 2018 Diciembre | 44 | 55 | 99 |
| 2018 Noviembre | 46 | 12 | 58 |
| 2018 Octubre | 33 | 9 | 42 |
| 2018 Septiembre | 28 | 11 | 39 |
| 2018 Agosto | 25 | 13 | 38 |
| 2018 Julio | 11 | 8 | 19 |
| 2018 Mayo | 4 | 0 | 4 |
| 2018 Abril | 30 | 8 | 38 |
| 2018 Marzo | 38 | 8 | 46 |
| 2018 Febrero | 27 | 6 | 33 |
| 2018 Enero | 13 | 10 | 23 |
| 2017 Diciembre | 31 | 7 | 38 |
| 2017 Noviembre | 22 | 9 | 31 |
| 2017 Octubre | 21 | 6 | 27 |
| 2017 Septiembre | 30 | 8 | 38 |
| 2017 Agosto | 45 | 10 | 55 |
| 2017 Julio | 32 | 13 | 45 |
| 2017 Junio | 65 | 17 | 82 |
| 2017 Mayo | 59 | 14 | 73 |
| 2017 Abril | 39 | 8 | 47 |
| 2017 Marzo | 39 | 29 | 68 |
| 2017 Febrero | 31 | 15 | 46 |
| 2017 Enero | 30 | 16 | 46 |
| 2016 Diciembre | 45 | 20 | 65 |
| 2016 Noviembre | 39 | 14 | 53 |
| 2016 Octubre | 49 | 18 | 67 |
| 2016 Septiembre | 28 | 4 | 32 |
| 2016 Agosto | 26 | 16 | 42 |
| 2016 Julio | 12 | 5 | 17 |
| 2016 Junio | 0 | 5 | 5 |
| 2016 Mayo | 0 | 11 | 11 |
| 2016 Abril | 0 | 6 | 6 |
| 2016 Marzo | 0 | 9 | 9 |
| 2016 Febrero | 0 | 12 | 12 |
| 2016 Enero | 0 | 22 | 22 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Noviembre | 0 | 17 | 17 |
| 2015 Octubre | 2 | 0 | 2 |
| 2015 Septiembre | 2 | 14 | 16 |
| 2015 Agosto | 2 | 0 | 2 |
| 2015 Julio | 16 | 6 | 22 |
| 2015 Junio | 29 | 8 | 37 |
| 2015 Mayo | 53 | 17 | 70 |
| 2015 Abril | 34 | 16 | 50 |
| 2015 Marzo | 30 | 6 | 36 |
| 2015 Febrero | 34 | 0 | 34 |
| 2015 Enero | 27 | 0 | 27 |
| 2014 Diciembre | 39 | 0 | 39 |
| 2014 Noviembre | 21 | 0 | 21 |
| 2014 Octubre | 33 | 0 | 33 |
| 2014 Septiembre | 31 | 0 | 31 |
| 2014 Agosto | 38 | 0 | 38 |
| 2014 Julio | 42 | 0 | 42 |
| 2014 Junio | 35 | 0 | 35 |
| 2014 Mayo | 39 | 0 | 39 |
| 2014 Abril | 36 | 0 | 36 |
| 2014 Marzo | 33 | 11 | 44 |
| 2014 Febrero | 19 | 14 | 33 |
| 2014 Enero | 21 | 8 | 29 |
| 2013 Diciembre | 29 | 15 | 44 |
| 2013 Noviembre | 16 | 10 | 26 |
| 2013 Octubre | 34 | 9 | 43 |
| 2013 Septiembre | 29 | 10 | 39 |
| 2013 Agosto | 30 | 17 | 47 |
| 2013 Julio | 26 | 8 | 34 |
| 2013 Junio | 24 | 6 | 30 |
| 2013 Mayo | 23 | 7 | 30 |
| 2013 Abril | 32 | 13 | 45 |
| 2013 Marzo | 27 | 12 | 39 |
| 2013 Febrero | 26 | 8 | 34 |
| 2013 Enero | 23 | 3 | 26 |
| 2012 Diciembre | 17 | 6 | 23 |
| 2012 Noviembre | 12 | 11 | 23 |
| 2012 Octubre | 15 | 12 | 27 |
| 2012 Septiembre | 13 | 28 | 41 |
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