Rheumatology Practice Changers 2014

Bret S. Stetka, MD; Stephen A. Paget, MD


December 18, 2014

In This Article

Treating to Target

"Treat to target" remains the gold standard for the treatment of not only RA but also other systemic disorders, such as spondylolarthritides, scleroderma, and SLE—all disorders in which the goal is to limit or stop tissue damage in one organ system or another. The primary target in treatment of RA should be a state of clinical remission, defined as the absence of signs and symptoms of significant inflammatory disease activity; low disease activity may be an acceptable alternative therapeutic goal, particularly in established, long-standing disease.

According to this construct, until the desired treatment target is reached, drug therapy should be adjusted at least every 3-6 months. To attain such a goal, measures of disease activity must be obtained and documented regularly, as frequently as monthly for patients with high or moderate disease activity, or less frequently (such as every 3-6 months) for patients with sustained low disease activity or remission.

The use of validated composite measures of disease activity, which include joint assessments, is needed in routine clinical practice to guide treatment decisions. The major metrics used to define the effectiveness of such a treatment protocol (and which have been validated for this purpose) are prevention of joint damage, decrease in disease activity, and improved function. In addition, mortality is particularly important in a disease that shortens life.

Recent work shows diverging results on mortality trends in patients with RA. A study[11] from The Netherlands, presented at the 2014 ACR meeting, focused on determining survival after 10 years of treat-to-target therapy in patients with early RA. The study compared survival rates with those in the general population and attempted to define risk factors for mortality during the 10 years' duration of the BeSt study, in which 508 Dutch patients with recent-onset active RA (per the 1987 criteria) were randomly assigned to receive sequential monotherapy, step-up therapy, or initial combination therapy including either prednisone or infliximab.

After 10 years of continued tightly controlled treatment, the survival rate was similar to that in the general Dutch population, regardless of treatment strategy. Older age, male sex, smoking, and worse functional ability were associated with an increased risk for mortality within the study population. These results suggest that treatment targeted at a DAS ≤ 2.4 prevents increased mortality in RA, and that the medication used does not affect mortality.


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