Intention to apply treat-to-target may be enough to reduce radiological progression in rheumatoid arthritis, research shows.
A study of a treat-to-target (T2T) strategy in rheumatoid arthritis patients has concluded that intention to apply T2T may be enough to reduce radiographic progression.
The two-year prospective observational study included more than 500 patients in 10 countries, with results published in Rheumatology.
Patients were grouped according to degree of adherence to a T2T protocol, with researchers finding no significant difference in the degree of radiographic progression among groups.
“One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome,” wrote the authors, led by Dr Sofia Ramiro of the Leiden University Medical Center in the Netherlands.
The authors suggested that a more lenient approach to T2T may be adequate and in some cases more appropriate – for avoiding potential overtreatment, for example.
Rheumatologists in the study were required to use a T2T strategy using DAS44 remission (DAS44<1.6) as a benchmark.
If a patient didn’t meet remission criteria at visits and treatment was intensified, or a patient met remission criteria and treatment wasn’t intensified, T2T was considered as being followed.
Adherence to T2T was assessed at each three-monthly visit for 21 months and each patient was categorised as very low, low, high and very high according to the final proportion of the visits following T2T.
Radiographic damage in hands and feet was assessed every six months and scored using the Sharp-van der Heijde (SvdH) method, providing a total score over 44 joints ranging from 0 to 448.
The authors had previously shown with the same group of patients that following a T2T strategy based on disease activity resulted in more patients meeting the remission criteria. However, they noted there were few trials looking at progression of structural damage and results were conflicting.
In this study, degree of adherence to T2T did not result in significantly different radiographic progression.
While suggesting the intention to apply T2T was key to preventing radiographic damage progression, the authors acknowledged that starting appropriate treatment earlier – that is, before structural damage began to develop – may be of more value than strict adherence to T2T after damage had occurred. The patients in the group had had the disease for a mean of seven years, which may explain the negative results.
Professor Susanna Proudman, director of the rheumatology unit at the Royal Adelaide Hospital, pointed out that radiographic progression had lessened over time, not just because of the advent of new DMARDs but due to strategies for early diagnosis and treatment.
“At the Royal Adelaide Hospital, we adopted a T2T approach more than two decades ago and we have seen minimal, if any, radiographic progression,” Professor Proudman said.
“I would agree with the authors’ conclusion that the ‘intention’ rather than the strict application of applying a T2T strategy may be the key. It is not possible to apply T2T strictly in every case as the curve representing improvement in disease activity can be asymptotic – that is, one gets close to but may never reach the chosen target.
“On the other hand,” she said, “close attention to routinely measuring disease activity using a composite marker of patient assessment, joint counts and an inflammatory marker shifts the dial towards optimal suppression of the inflammatory burden early and over time. It is easier to influence the natural history of the disease if you can measure it.
“It is a balancing act between optimal disease suppression and a continued increase in therapy without additional benefit that risks becoming overtreatment.”
