Rheumatoid arthritis (RA) is a systemic autoimmune disease whose main characteristic is a chronic inflammation of diarthrodial joints. In absence of a successful therapy, RA leads to irreversible destruction of articular structure, functional impairment and loss of quality of life.

With the advent of biologic therapy and the optimal use of conventional disease-modifying anti-rheumatic drugs (DMARDs), being methotrexate (MTX) the corner-stone of RA treatment, remission of disease or, at least, a state of low disease activity (LDA) are considered nowadays realistic goals in the management of RA, as different guidelines and recommendations suggest.1–3

Several studies have compared standard of care by personal rheumatologist's judgement deciding the changes in therapy versus thigh control and dynamic escalation of the therapy according to pre-specified therapeutic targets.4–7 These studies have demonstrated better outcomes with the so called “treat to target” (TTT) strategies. Thus, the current paradigm of optimal clinical care of patients with RA recommends reaching a state of remission or LDA of the disease, assessed by composite indexes of activity, by means of a tight control and a dynamic adjustment of available therapeutic options, using a TTT strategy.8,9

Although the TTT strategy is widely known and assumed by rheumatologists as beneficial and feasible,10–12 there are barriers in routine clinical practice that could hinder its wide implementation and the optimal management of RA patients. The objective of our study was to objectively assess the level of implementation of the TTT recommendations in routine clinical care of RA patients.

This study is an audit of clinical records of patients diagnosed of RA and managed in Spanish rheumatology units.

All the rheumatology units of Spain were invited to participate in the study. Those units that accepted to participate sent to the research team a computerized anonymized list of adult patients fulfilling the 2010 ACR-EULAR criteria for RA13 and diagnosed of RA between January 1st, 2010 and December 31st, 2013.

In order to accomplish an adequate representation of the RA population, 19 patients were randomly chosen from the list provided by every department.

Independent auditors, specifically trained by the research team, assessed the clinical records, verifying the fulfilling of the TTT recommendations in the management of the patients. Clinical, epidemiological and demographic data were recorded from every patient.

The study was approved by the ethic committees of every participant hospital. Descriptive statistics was used for the presentation of the results.

Forty-six rheumatology units participated in the study. From them, a total of 856 clinical records, randomly chosen, were available for the audit. Table 1 shows the characteristics of the patients. Mean age of them was 54 years and 71% of patients were women. Mean duration of RA was 2 years.

An explicit assessment of the disease activity as a determinant element considered to select the therapy was recorded in 32% of the CRs. Use of at least a composite disease activity score (DAS28, SDAI or CDAI) was recorded in 61% of the cases. In the follow-up, 38% of patients reached a state of low disease activity, defined by a DAS28 <3.2 and/or a SDAI ≤11.

In only 4% of the CRs, appointments every 4 weeks using a composite activity score had been recorded during the early stage while trying to reach remission after the diagnosis of RA.

Disease activity monitoring every 6–8 months after reaching the therapeutic target was recorded in 73% of the cases.

In 99% of the cases, the clinicians had registered patient's comorbidities and these associated conditions had been considered in planning the therapeutic approach and objective.

Our data have shown a low implementation of the TTT strategy in the routine clinical practice of the rheumatology units participating in the study. The data are somewhat disappointing since the widespread dissemination of TTT strategy and the acceptance of their feasibility by rheumatologists14 would lead to the expectation of a wider implementation of this treatment strategy.

There are several barriers that have been suggested for the implementation of the TTT strategy.15 Likely, the main ones are the lack of time in real world clinical practice to use the compound indices of activity and the difficulty to get appointments for the patients with RA month by month during the escalation of medication to achieve a state of remission or, at least, LDA. A potential solution would be to maintain preferential citation slots in order to monitor patients every 1–3 months. This would require an additional effort in rheumatologist resources but, on the other hand, the TTT strategy has been shown to be more effective than usual care16 and even cost-efficient in the medium and long term.17

Although our results are quite disappointing, we used a very stringent criterion, four weeks, to judge whether the TTT strategy was being followed. Likely, the results would not have been so poor if we had used 3 months instead of 4 weeks as the criterion of excellence to adjust the treatment of patients with RA during the escalation of therapy in order to reach a state of remission or LDA.

In conclusion, a minority of the patients with RA are managed according to the TTT strategy, that is, using combined indices of activity to monitor the response to treatment and follow-up every 4 weeks until the therapeutic goal is achieved.

This article does not contain any studies with human participants or animals performed by any of the authors.

This study was funded by an unrestricted grant provided by the biopharmaceutical company AbbVie.

The authors declare no conflict of interest. Ángel Gil de Miguel declares that he is Director of the Chair of Evaluation of Health Outcomes Universidad Rey Juan Carlos/Abbvie.