Rheumatoid Arthritis: Updated Recommendations Released

Janis C. Kelly

May 28, 2015

The updated treat-to-target recommendations (T2T) for rheumatoid arthritis (RA) are based on stronger evidence than the earlier version, which was published in 2010, and emphasize the importance of shared decision-making between the rheumatologist and the patient for selecting both the target and the treatment strategy. The revised recommendations were published online May 12 in the Annals of the Rheumatic Diseases by an international task force led by Josef S. Smolen, MD, from the Division of Rheumatology at the Medical University of Vienna, Austria.

Coauthor Vivian Bykerk, MD, told Medscape Medical News, "This primarily reports on strengthened evidence, but also there is more focus [on] ensuring that clinicians take patients' other comorbid health conditions into account and to ensure that patient preference is included in decision making." Dr Bykerk is associate attending rheumatologist, Hospital for Special Surgery; associate professor of medicine, Weill Cornell Medical College; and director, Inflammatory Arthritis Center of Excellence, Hospital for Special Surgery, New York City.

Eric M. Ruderman, MD, professor in medicine-rheumatology and clinical practice director for the Rheumatology Clinic at Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News that the problem in 2010 was that most of the recommendations were based on expert opinion because there were no firm prospective data showing that T2T worked. Dr Ruderman was not involved in the study.

RA Remission Remains Treatment Target

The update maintained the key recommendation that the primary target of RA treatment be clinical remission, defined as absence of significant inflammatory disease activity. In cases such as long-standing disease, where remission is unattainable, the guidelines recommend low disease activity as an acceptable alternate target.

"This update 5 years later repeated the literature review and showed that there are now objective data to support many of the recommendations. The authors asked whether any of the recommendations needed major changes, and the answer is 'No.' The major change from 2010 is that [the] strength of many recommendations is much higher due to published evidence," Dr Ruderman said.

"The challenge is that not everybody is actually following the recommendations, at least in the US. Most would say that they are measuring objective, reproducible measures of disease activity (including joint counts and physical examination), but many clinicians are not measuring disease activity in every RA patient at every visit, and many are not making treatment decisions based on such measurements. When T2T was based only on expert opinion, it was easier to dismiss. Now it is more evidence-based, and T2T is what we are going to be forced to do as quality measurements become more central to healthcare. This update showed that in RA, treating to target is associated with better outcomes."

Update Stresses Regular Use of Composite Disease Activity Measures

The update maintained the four overarching principles of the original recommendations and added stronger evidence that emerged after the 2010 recommendations were issued. The updated recommendations reordered some of the 10 recommendations to emphasize the use of validated composite measures of disease activity in routine clinical practice, to highlight the importance of comorbidities as a factor in choice of disease activity measures and of treatment target, and to recognize the increasing importance of professionals other than physicians (especially specialist nurses) in RA care.

"The challenge in RA is that there is no single objective measure. The task force was faced with 2 issues: whether treating-to-target would achieve better outcomes, and how to identify the target in the absence of any single objective measure. They chose remission as the target, or low disease activity if remission could not be achieved," Dr Ruderman explained.

Unanswered Questions

Dr Bykerk said that moving forward, a key question is how to know much earlier what will be the best first choice therapy for the individual patient with RA. "Determining an order of therapy that is rational is an unmet need. Also, there are still 10% to 30% of patients in whom current therapies are used, but without sufficient effect," Dr Bykerk said.

Uncertainty also remains about how frequently to follow patients with RA. The recommendations state, "Measures of disease activity must be obtained and documented regularly, as frequently as monthly for patients with high/moderate disease activity or less frequently (such as every six months) for patients in sustained low-disease activity or remission."

"The only point likely to create push-back concerns the frequency of follow-up. When we did a T2T study, we found that the patient may not have time to come in every month, and I don't have time in my schedule to see every patient every month. The authors shifted the emphasis toward 3 months when starting treatment. You don't make changes a month at a time, especially after prescribing a new drug that may take 3 months to work," Dr Ruderman said.

"Furthermore, once you have the patient at target (either remission or low disease activity), the new recommendation is follow-up at 6 months, or even less often. That acknowledges that we have so many good treatments that once you get somebody under good disease control, they are likely to remain stable for a very long time. Once you achieve the target, you don't have to keep constantly tweaking treatment," Dr Ruderman added.

There is also growing interest in use of newer communications technologies to help improve communication between clinicians and patients. Dr Bykerk said, "I think apps and email aids can help patients stay on target and meet their goals."

The study was supported by an unrestricted educational grant from Abbvie to the Medical University of Vienna. Dr Smolen and several coauthors report having served as consultants, received grant support, provided expert advice to, participated at symposia and/or advisory boards organized by, undertaken clinical trials for, received speaking fees from, received honoraria from, served as directors of, or owned stock in Abbvie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Chugai, GlaxoSmithKline, Janssen, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung, UCB, Genentech, Crescendo, Antares, Medexus, Lilly, Sanofi, Takeda, Celltrion, Hospira, Merck Serono, Orion Pharma, Regeneron, Astellas, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, Santen, Asahikasei, Taisho Toyama, SymBio, Nipponkayaku, Asahi Kasei, Medac, Grunenthal, Mundipharma, SUN, Crescendo, Hemics, Infinity, Horizon, Iroko, Jansen&Jansen, Abbott, Novo-Nordisk, TiGenics, Rheumatology Consultancy BV, DiaGraphIT, Muikkusäätiö, Biotest, Vertex, Augurex, Covagen, Galapagos, Janssen Biologics, Otsuka, and Imaging Rheumatology. The remaining coauthors and Dr Ruderman have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online May 12, 2015. Full text

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