How can you and your rheumatologist take the guesswork out of your rheumatoid arthritis (RA) treatment? Together, you can set specific goals or targets for your RA treatment. This strategy is called treat to target, or T2T.
What Is Treat to Target?
Treat to target is RA treatment based on your disease activity. When you treat to target, you adjust your medications until you reach specific targets on your test results. You take regular tests to track your disease activity and make changes to your treatment when and if needed.
What’s the Goal of Treat to Target?
Usually, your goal for RA treatment is remission. This is when you have no clinical signs of active inflammation.
RA remission is based on your blood tests, physical exam, and questionnaires that you fill out to measure how your arthritis affects your daily life and function. At first, you may be tested every month to see if you’re reaching your target.
If your RA is in remission, you meet these targets:
- One or no tender joints out of 28
- One or no swollen joints out of 28
- C-reactive protein (CRP) blood test result of 1 mg/dl or lower
- On a scale from 0-10, you assess your RA activity at 1 or 0. This score is based on a standard questionnaire about your symptoms and physical function with RA.
RA remission can also be measured with a test called the Simplified Disease Activity Index (SDAI), which combines how many of 28 of your joints are tender and swollen, CRP levels, and how you and your doctor assess RA’s impact on your daily life and function. Your SDAI score will be 3 or lower if you’re in remission.
Not everyone with RA chooses to set remission as a target. You can also treat to a target of very low disease activity.
You may decide that very low disease activity is a more realistic goal for you. Some people with RA can be discouraged if they don’t reach remission. If you reach a low disease activity goal, you can always change your treatment to target remission next.
Usually, you and your rheumatologist will evaluate your progress at least as soon as 3 months after you start T2T to see if you need to make any changes to your medications.
Is T2T More Effective?
Before T2T, rheumatologists treated RA by adjusting medications based on their own judgment, not with frequent disease activity testing. This is called routine care.
T2T is proven to work to help you reach RA remission. In the Dutch Rheumatoid Arthritis Monitoring (DREAM) trial of 342 people with RA, 61.7% of patients who were treated to target achieved remission after 3 years, and 70.5% achieved sustained remission.
More data from the DREAM trial compared 126 people with RA treated to target and 126 who were treated without frequent testing as a guide. After 1 year, 55% of people treated to target achieved remission compared with 30% of people without guided treatment. In addition, people treated to target reached remission at a median time of 25 weeks compared to 52 weeks for those treated without a target. People treated to target also lowered their RA disease activity more than the other group.
How Do You Get to Your Target?
If your disease activity is moderate to high, your rheumatologist will first prescribe methotrexate (Otrexup, Rasuvo, Rheumatrex, Trexall), a disease-modifying antirheumatic drug, or DMARD. Oral methotrexate pills are recommended over injections.
Another option is triple therapy. This is a combination of either methotrexate or leflunomide (Arava) with two other DMARDs, hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
Your doctor may also choose to prescribe methotrexate with a biologic drug called a TNF blocker. Either methotrexate alone or combined with a TNF blocker may work faster than triple therapy.
If you have low disease activity, your doctor may prescribe hydroxychloroquine instead of methotrexate.
When Is It Time to Change Treatments?
The goal is to treat your RA to reach your target within 3 to 6 months after diagnosis. You may need to see your rheumatologist for testing every month to 3 months to see if you’ve hit your target.
If you don’t reach your target, your doctor may add one of these biologics to your methotrexate to help you get there:
- TNF blocker like etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), golimumab (Simponi, Simponi Aria), or certolizumab pegol (Cimzia)
- Abatacept (Orencia), a T-cell inhibitor
- IL-6 inhibitor like tocilizumab (Actemra) or sarilumab (Kevzara)
- JAK inhibitor like tofacitinib (Xeljanz), baricitinib (Olumiant), or upadacitinib (Rinvoq)
Other treatment options if you don’t reach your target with oral methotrexate is to switch to the injected form of the drug or to try triple therapy.
If you’re taking methotrexate and a biologic and still don’t reach your target, your doctor may switch you to a biologic that works differently than the one you’ve used.
If none of these treatment plans lower your disease activity to target, your doctor may prescribe a steroid for a short time only.
How Will You Know You’re at Target?
You’ll have blood tests and physical exams to check your disease activity as often as once a month to see if you’ve reached your target or to make changes to your treatment plan until you get there.
If You Reach Your Target, Can You Taper Your Treatment?
If you’re at your target for at least 6 months, you and your rheumatologist may decide to taper your treatment.
You’ll either you lower the dose of your drug, take each dose less often, or gradually lower your dose until you stop taking your drug altogether. It’s better for most people with RA to keep taking a lower dose of your drug rather than stopping. Even if you don’t have joint pain or swelling, you can still have low levels of inflammation that could damage joints over time.
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Arthritis Foundation: “Treat to Target Approach Improves RA Outcomes,” “Your RA Is in Remission: Now What?” “New Guidelines for Rheumatoid Arthritis Treatments.”
American College of Rheumatology: “2011 RA Remission Criteria.”
Arthritis Care & Research: “2021 American College of Rheumatology Guideline for the
Treatment of Rheumatoid Arthritis,” “Sustained Beneficial Effects of a Protocolized Treat-to-Target Strategy in Very Early Rheumatoid Arthritis: Three-Year Results of the Dutch Rheumatoid Arthritis Monitoring Remission Induction Cohort.”
Annals of the Rheumatic Diseases: “A tight control treatment strategy aiming for remission in early rheumatoid arthritis is more effective than usual care treatment in daily clinical practice: a study of two cohorts in the Dutch Rheumatoid Arthritis Monitoring registry.”
Clinical Medicine Journal: “The ‘therapeutic window’ and treating to target in rheumatoid arthritis.”
Journal of Clinical Medicine: “Current Therapeutic Options in the Treatment of Rheumatoid Arthritis.”