Is treat-to-target really working for people with rheumatoid arthritis?

Treat-to-target is a highly accepted treatment approach for people with RA, but its success in leading patients to reach the target of remission or low disease activity has never been assessed. Researchers recently set out to do just that in the BIODAM study, which is an international study aimed at the validation of biomarkers as predictors of joint damage and development of a personalized treatment strategy for patients with RA.

"Treating towards remission is nowadays one of the main aims in the treatment of patients with RA, explains lead investigator in the study, Sofia Ramiro, MD, PhD; Leiden University Medical Center; Leiden, the Netherlands. "We have evidence that remission is the best outcome for patients, and therefore the treat-to-target strategy is recommended. However, until now, we didn't have any study assessing the impact of following treat-to-target strategy on disease activity outcomes over time. BIODAM provided an optimal setting to test this, as patients from several countries are followed up over time, while rheumatologists are encouraged to follow a treat-to-target strategy."

Dr. Ramiro's team followed 539 patients over the course of two years in a total of 3,084 visits. The patients had an average age of 56 years; 76 percent were female; they had RA for an average of 6 years; and 49 percent had never taken a disease modifying antirheumatic drug (commonly called DMARDs).

The patients were either started on or switched to a DMARD and/or anti-TNF at the beginning of the study and received follow up every three months throughout the course of the study. At each follow up, it was determined if the participant had been successfully treated to target. At that visit, those who

did not achieve a disease activity score below the target of DAS28 of less than or equal to 2.6 had their treatment intensified by increasing the dosage of their medication or adding new therapies. Alternatively, the researchers looked at a treat-to-target strategy with the target being low disease activity with a DAS28 less than 3.2.

Dr. Ramiro's team looked at disease activity three months after each visit to assess the efficacy of the treat-to-target strategy. Disease activity outcomes were measured as ACR/EULAR boolean remission, DAS28 remission (less than 2.6), DAS28-LDA (less than 3.2), and also according to two other instruments used to assess disease activity (Clinical Disease Activity Index -- CDAI -- and Simplified Disease Activity Index -- SDAI).

In 68 percent of the visits, a treat-to-target strategy for remission (target: DAS28 less than 2.6) was followed, while in 79 percent of the visits, a treat-to-target strategy for low disease activity (target: DAS28 less than 3.2) was followed. Upon examining these treatment approaches, the researchers noted the likelihood of achieving remission based on ACR/EULAR criteria was 52 percent higher when a participant was treated to target (target being remission) compared to a patient not following the treat-to-target strategy. They also found that both treat-to-target strategies (remission and low disease activity) led to lower disease activity. Finally, the researchers noted that patients who had never received DMARDs were more likely to go into remission when following the treat-to-target strategy than those who had taken them.

"A treat-to-target approach, even with a modest benchmark (low disease activity, or DAS28 less than 3.2), works immediately and leads to higher remission rates," concludes Dr. Ramiro. "Treat to target is more effective in DMARD-naïve than in DMARD-experienced patients, and rheumatologists should be encouraged to follow a treat-to-target approach in order to improve the outcome of their patients."