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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.
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Despite evidence demonstrating improved clinical outcomes in RA using a TTT strategy, it is not widely used in rheumatology in North America.
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Access to rheumatology care, physician and patient engagement, and systems issues provide
Challenges in Implementing Treat-to-Target Strategies in Rheumatology
Section snippets
Key points
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
References (42)
- et al.
Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial
Lancet
(2004) - et al.
Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group
Lancet
(1999) - et al.
Implementation of treat-to-target in rheumatoid arthritis through a Learning Collaborative: rationale and design of the TRACTION trial
Semin Arthritis Rheum
(2016) - et al.
Patient-reported outcomes in rheumatoid arthritis
Rheum Dis Clin North Am
(2016) - et al.
Mobile apps for individuals with rheumatoid arthritis
J Clin Rheumatol
(2018) - et al.
Reducing adverse drug events: lessons from a breakthrough series collaborative
Jt Comm J Qual Improv
(2000) - et al.
Treat to target, remission and low disease activity in SLE
Best Pract Res Clin Rheumatol
(2017) - et al.
Review: treat to target in rheumatoid arthritis: fact, fiction, or hypothesis?
Arthritis Rheumatol
(2014) - et al.
Treating rheumatoid arthritis to target: recommendations of an international task force
Ann Rheum Dis
(2010) - et al.
Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force
Ann Rheum Dis
(2016)
2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis
Arthritis Care Res (Hoboken)
EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update
Ann Rheum Dis
Evidence for treating rheumatoid arthritis to target: results of a systematic literature search
Ann Rheum Dis
Intensive treatment with methotrexate in early rheumatoid arthritis: aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial)
Ann Rheum Dis
Effectiveness of systematic monitoring of rheumatoid arthritis disease activity in daily practice: a multicentre, cluster randomised controlled trial
Ann Rheum Dis
The British Rheumatoid Outcome Study Group (BROSG) randomised controlled trial to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis
Health Technol Assess
Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial
Arthritis Rheum
Triple therapy in early active rheumatoid arthritis: a randomized, single-blind, controlled trial comparing step-up and parallel treatment strategies
Arthritis Rheum
Patterns of disease-modifying antirheumatic drug use in rheumatoid arthritis patients after 2002: a systematic review
Arthritis Care Res (Hoboken)
Use of disease-modifying medications for rheumatoid arthritis by race and ethnicity in the National Ambulatory Medical Care Survey
Arthritis Care Res (Hoboken)
Primary care physicians’ perspectives towards managing rheumatoid arthritis: room for improvement
Arthritis Res Ther
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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.