Treat-to-Target Hot Debate in Ankylosing Spondyloarthritis

Ingrid Hein

October 05, 2018

GHENT, Belgium — A heated debate about whether rheumatologists should use a treat-to-target approach for patients with ankylosing spondyloarthritis caused 22% of the audience at the International Congress on Spondyloarthritides 2018 to change their minds.

In a vote taken before the debate, 71% of audience members said they believed that treat-to-target should be used, but in a second vote taken at the end of the debate, only 49% maintained this position.

"Treat-to-target means having a goal that you predefine," said Atul Deodhar, MD, from the OHSU Hospital in Portland in Oregon, who was the debater designated to speak against the approach.

"If you think about it, how many patients go into remission — 25% to 30%?" he asked. "Our patients do well not because we have treat-to-target, but because we have better drugs than we used to."

Adhering to a treat-to-target protocol can mean seeing patients every 4 weeks, but most clinics can't see a patient that frequently. Deodhar said that at his clinic, patients can only be seen once every 3 months.

And treatment options are not plentiful, he added. "There are limited arrows to hit the 'target.' We only have TNF inhibitors and IL-17 blockers. You can't change drugs indefinitely."

Limited Arrows to Hit the Target

"It's not about the number of weeks to treat. It's about the concept," argued Pedro Machado, MD, PhD, from University College London, who was the designated defender in the debate. "We know it's a concept that's important in clinical practice. And it's a challenge. You have to have common sense."

Treat-to-target works for axial spondyloarthritis in clinical research, he acknowledged, but "when it comes to applying it in the clinical setting, that's another story."

The local health system needs to be taken into account, including funding, said Machado. "The concept has to be adapted to the country."

Organizers put the treat-to-target debate on the roster at the 2018 conference to air disagreements that arose after recommended targets for the treat-to-target management of ankylosing spondyloarthritis were published last year (Ann Rheum Dis. 2014;73:6-16).

Treat-to-target may lead to overtreatment.

"The fact is, we all agree we have to give patients the best possible treatment," said Filip Van den Bosch, MD, from Ghent University Hospital, who was one of the meeting organizers. "But treat-to-target may lead to overtreatment."

There are still questions about the level of disease activity that warrants treatment, he explained. "You try to make this as objective as possible. When do I do something? When is it okay?"

You know that when blood sugar reaches a certain level in a patient with diabetes, there will be consequences. And high blood pressure can lead to a heart attack. But it's not as simple for ankylosing spondyloarthritis, said Van den Bosch.

Although the Ankylosing Spondylitis Disease Activity Score (ASDAS) is valuable for making treatment decisions, there are no hard and fast rules, he explained. And specialists understand the danger a rule using ASDAS could pose.

For example, other clinical factors could outweigh a rule that states that an ASDAS value of 2.2 indicates treatment but a value of 2.0 does not.

"If you have a nonsmoking female, you might need to make a decision to augment or taper treatment," he said. "But we have to treat if there are inflammatory conditions."

If a patient has had medical treatment for 3 months and their ASDAS levels are still not acceptable, "that may mean we have to change the treatment," he added.

And if patients miss a few doses of their medication, the decision becomes more complex, Van den Bosch pointed out. It would depend on all the factors and patient-specific explanations.

"General practitioners don't know what's behind the ASDAS score," he added.

This is the basic trouble with this disease, he said. Even diagnosis is not as simple as checking three boxes on a list of indications. "That's why I think we're a little reluctant to bring this to the general health community."

The problem in medicine is the tendency to design algorithms to make it easy, so everyone can do this, Van den Bosch explained. In clinical trials, sometimes that will work, but "in reality, it doesn't. Some take well to therapy, others don't."

Deodhar and Machado report financial relationships with UCB. Van den Bosch reports receiving research support from Janssen, Merck, and UCB, and consultation fees from AbbVie, Bristol-Myers Squibb, Celgene, Galapagos, Janssen, Lilly, Novartis, Pfizer, Sanofi, and UCB.

International Congress on Spondyloarthritides (SPA) 2018. Presented October 5, 2018.

Follow Medscape Rheumatology on Twitter @MedscapeRheum and Ingrid Hein @ingridhein

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