Treating to Target in Rheumatology
In the field of rheumatology, the first serious investigations of the treat-to-target principle began in the 1990s, without using this particular terminology. The Finnish Rheumatoid Arthritis Combination (FinRACo) trial compared combination therapy with monotherapy in rheumatoid arthritis (RA), featuring a design in which remission (as defined by the Pinals remission criteria) was explicitly identified as the outcome (target) against which the patient's status at each follow-up point was measured. If the patient did not achieve remission, a change in therapy was made (staying within the monotherapy arm vs the combination therapy arm). Thus, treatment to target was implemented in both arms, and this may have contributed to the outstanding results in both treatment groups, with a difference favoring combination therapy.
The first formal evaluation of the treat-to-target principle in RA was conducted in the TIght COntrol in RA (TICORA) trial. Patients with newly diagnosed RA were randomly assigned to receive regular care (given by specialists at rheumatology clinics, with visits every 3 months, and with therapy decisions based on clinical impressions) vs treat-to-target (monthly visits to the specialist or nurse-specialist, mandatory assessment at every visit to determine whether remission according to the Disease Activity Score [DAS]-28 had been achieved, and therapy adjustment if not).
The trial clearly demonstrated that the latter strategy was superior to usual care, even though usual care in this trial was what many would consider to be a very good level of specialty care for patients with a straightforward rheumatologic diagnosis. Of note, the results in TICORA were obtained almost entirely with conventional medications, underscoring that it was the strategy of how the medications were used, rather than the medications themselves, that made the difference.
Several other trials demonstrated the superiority of a treat-to-target strategy in RA, including the CAMERA trial, which also featured a computerized decision-making algorithm to support clinicians. After the demonstration in these trials of the superiority of the strategy, an international expert panel published treat-to-target recommendations for RA in 2010. These recommendations have been extensively discussed and are increasingly being implemented in the care of patients with this disease.
Since then, treat-to-target recommendations have also been developed for psoriatic arthritis and spondyloarthritis. These developments raised the question of whether treating to target would be applicable to the care of patients with SLE as well, and this was the starting point for the international expert panel in 2012.
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