Challenges in Implementing Treat-to-Target Strategies in Rheumatology

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Key points

  • Treat-to-target (TTT), as defined in rheumatoid arthritis (RA), uses shared decision-making between physicians and patients to select a disease activity target, routinely assess disease activity, and adjust therapy accordingly to achieve and maintain the target.

  • Despite evidence demonstrating improved clinical outcomes in RA using a TTT strategy, it is not widely used in rheumatology in North America.

  • Access to rheumatology care, physician and patient engagement, and systems issues provide

Treat-to-target principles and evidence-base in rheumatoid arthritis

The TTT model for RA is based on the core principles and recommendations as outlined by an international working group.2, 3 First, the physician and the patient should identify a disease activity target using shared decision-making. For most RA patients, the target should be clinical remission or, in some cases, low disease activity. Low disease activity may be more appropriate for patients with many comorbidities or long-standing RA. Second, disease activity should be measured regularly using

Access to Care

A major challenge to more widespread implementation of TTT in clinical practice is access to rheumatology subspecialty care. A systematic review of observational studies of patients with early and established RA reported that, even after publication of ACR guidelines supporting universal DMARD use in active RA, only 30% to 73% of RA patients in administrative or population-based studies (who were not necessarily under the care of a rheumatologist) were prescribed a DMARD. DMARD use in studies

Possible solutions to challenges in treat-to-target implementation

Clearly, successful implementation of a TTT strategy in RA care faces multiple challenges. Possible solutions and strategies for mitigating these barriers are presented in Table 1. Improving access to RA care will be essential to more widespread uptake of TTT. The rheumatology community would benefit from expanding and improving medical education for nonrheumatologists in RA diagnosis and management, starting at the medical school level and extending into residency and continuing medical

Spondyloarthritis

In contrast to RA, there are no randomized controlled trials comparing TTT to routine care in spondyloarthritis (including peripheral and axial spondyloarthritis and psoriatic arthritis).31 However, international task force guidelines32 embrace a TTT approach in spondyloarthritis with a recommended target of clinical remission and an alternative target of low disease activity, acknowledging importance of extraarticular aspects of these diseases. Potential barriers to effective implementation of

Questions and future directions

Many questions remain relating to TTT in RA and a proposed research agenda is presented in Box 1. A particularly interesting question is whether there is a therapeutic window of opportunity early in the course of RA during which aggressive treatment could meaningfully alter the disease trajectory and reduce chronicity or the need for long-term immunosuppression. A systematic literature review40 of 18 cohort studies and randomized controlled trials reporting outcome data in early RA showed that

Summary

Though TTT for RA is supported by evidence and endorsed by major rheumatology professional organizations, this strategy for care has not been widely embraced in the United States. Creative solutions are needed at the individual provider and patient level, as well as at a systems level, to propagate a TTT approach. Although TTT may be a useful and feasible strategy for more common rheumatic diseases (and those that have a strong set of evidence-based targets), less common diseases without clear

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    Disclosure Statement: Dr D.H. Solomon’s work was supported by NIH-AR-072577 (VERITY). He receives salary support from research support to Brigham and Women’s Hospital from Amgen, Pfizer, Abbvie, Genentech, Bristol-Myers Squibb, and CORRONA; and he receives royalties from UpToDate. Dr J.A. Ford has no disclosures.

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