San Francisco, CA—The strategy of treat-to-target (T2T) is paying off for patients with rheumatoid arthritis (RA) in daily clinical practice, according to a study presented at the 2015 annual meeting of the American College of Rheumatology (ACR). T2T of remission or low disease activity leads to longer sustained, higher rates of, and faster times to remission, the study shows.
These findings were released soon after the 2015 updated ACR guidelines for RA endorsed a T2T strategy. This approach is already in widespread use in many countries.
“Intuitively, we would expect the strategy of T2T to remission or low disease activity to lead to better outcomes, but this has not been formally tested. Our study shows that T2T works, leading to higher rates of remission, longer duration of sustained remission, and longer time to remission,” said lead author Sofia Ramiro, MD, PhD, of Leiden University Medical Center in the Netherlands.
“The findings are not surprising, but they are confirmatory,” she added.
The RA BIODAM study included 539 patients followed over 2 years for a total of 3084 patient visits. Average age was 56 years; 76% were female; median duration of RA was 6 years; and 49% had never taken a disease-modifying antirheumatic drug (DMARD).
Patients were switched to or given a DMARD, an anti–tumor necrosis factor biologic, or both, and were seen by a doctor every 3 months for 2 years. Those visits were considered T2T when the Disease Activity Score in 28 joints (DAS28) was ≤3.2, signifying remission, and treatment was unchanged, or when the DAS28 score was >3.2 and treatment was intensified. A visit was not considered T2T if the DAS28 was >3.2 and treatment was not intensified.
At every 3 months, outcomes assessed were ACR/EULAR (European League Against Rheumatism) remission, DAS28 remission (<2.6), DAS28 low disease activity (<3.2), and remission by Clinical Disease Activity Index and the Simplified Disease Activity Index criteria.
In 68% of visits, a T2T strategy was aimed at remission, a DAS28 of <2.6, whereas in 79% of visits, a T2T strategy was aimed at low disease activity, a DAS28 of <3.2.
Patients following T2T for ACR/EULAR remission were 52% more likely to achieve remission versus those who were not being treated to this target. Both T2T strategies (ie, target of remission or low disease activity) led to lower disease activity. Patients who had not received DMARDs prior to the study were more likely to achieve remission on T2T compared with those who had taken them.
The rate of sustained remission (ie, at least 6 months) was 64% higher in those managed by T2T.
Patients in the T2T group achieved remission 3.7 times faster compared with those not following this strategy.
Dr Ramiro and colleagues plan to look at structural damage in this patient cohort by assessing radiographs obtained every 6 months and scored. The goal will be to determine if following T2T leads to less damage.
“Our impression from this research is that rheumatologists are treating toward targets of low disease activity rather than remission. In one-third of visits, treatment was not intensified even if the patient did not achieve remission,” she said.
“Treatment intensification was seen more frequently with a higher DAS28 score. Perhaps doctors are satisfied with DAS28 of 3.2. The doctors do not aim for a target of remission when low disease activity is reached.”
“A T2T approach, even with a modest benchmark of low disease activity [DAS28 <3.2], works immediately and leads to higher remission rates. T2T is more effective in DMARD-naive patients than in DMARD-experienced patients, and rheumatologists should be encouraged to follow a T2T approach to improve the outcome of their patients,” Dr Ramiro stated.
The RA BIODAM study was funded by AbbVie.
Ramiro S, Landewé RBM, van der Heijde D, et al. Is treat-to-target really working? A longitudinal analysis in Biodam. Presented at: 2015 American College of Rheumatology Annual Meeting; November 7-11, 2015; San Francisco, CA. Abstract 3184.