An Important Shift in Lupus Care

Ronald F. van Vollenhoven, MD, PhD

Disclosures

July 21, 2014

In This Article

Treating to Target in Lupus

Despite significant advances in our understanding of the pathogenesis and clinical course of systemic lupus erythematosus (SLE), and a notable improvement in overall survival, the prospects for patients with this disease remain disappointing. Chronic and persistent symptoms, the pervasive risk for flares, the need for such long-term therapies as corticosteroids, and disease-related end-organ damage all contribute to significant reductions in health-related quality-of-life (HR-QOL) in SLE.[1] In a recent survey of patients with SLE in Sweden,[2] the average HR-QOL (where 0 is worst and 1.0 is best) was 0.62, a level -- similar to that seen in chronic obstructive pulmonary disease, moderate heart failure, HIV, and lymphoma. Moreover, direct and indirect costs of the disease are very high, underscoring the need for better therapies from a societal perspective.

These observations raise the question of how to achieve better outcomes of therapy. One reply could be newer and more effective therapeutic agents, and this is undoubtedly true.[3] However, another important possibility is that currently available therapeutics could be used more effectively. This possibility is suggested by data from other therapeutic areas, where treating to target has yielded results superior to usual care.

Treating to Target: The Principles

The concept of treating to target should not be confused with the development of targeted therapeutics, such as monoclonal antibodies directed against cytokines or cell-surface molecules. Instead, treating to target is defining a therapeutic goal (the target), measuring it, and adjusting therapy on the basis of whether the goal has been achieved. Treating to target is very similar to the idea of "tight control."

The treat-to-target concept originated in fields of medicine outside of rheumatology. It has been understood for decades that in treating hypertension, the purpose should not be to relieve symptoms, but to achieve risk reduction by meeting a specific blood pressure target. The ability to accurately measure blood pressure and the development of a range of new antihypertensive agents have made this eminently possible, and randomized controlled trials have proved that this approach yields better long-term results.[4] Similarly, in diabetes, targeting a specific A1c value (an easily measured goal), and using any of a large number of antidiabetes medications to achieve the target, have improved outcomes.[5]

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