Treat-to-Target Strategy

Many physicians, including my own rheumatologists, use a strategy known as treat-to-target when working with their RA patients. The idea is that the patient and the physician work closely together to decide on a goal and a treatment plan to reach it.

Treat-to-target in RA is similar to the strategy used for management of other chronic conditions, like diabetes and heart disease. Ideally, remission is the primary goal for those suffering from RA. The next best option is tightly controlled inflammation, what is known as low disease activity, which may be an appropriate target for many patients. Reducing inflammation to the lowest possible level protects your joints from further damage and can help prevent other health issues, such as heart disease or depression.

Setting a realistic goal starts with a baseline assessment by your physician to help determine how serious your disease is. Treat-to-target relies on regular medical evaluation to monitor progress towards the target and whether your RA improves, remains stable, or worsens with treatment. This monitoring includes information from you about pain and your level of functional impairment, physical examination by your physician to determine the number of swollen and tender joints, blood work to measure inflammation, and X-rays that may provide evidence of bone erosion and any underlying joint damage. Using one of several scoring tools that are available, results from the assessments are used by your doctor to measure your ongoing level of disease activity.

Treat-to-target means that you and your doctor decide on a goal and a time frame for achieving it. If you don't reach certain benchmarks, your physician may recommend increasing the dose, adding a medication, or switching to another one. Making changes may also involve one or more lifestyle changes-- quitting smoking, for example, or losing weight. The treat-to-target approach doesn't change if you have high disease activity. The difference is you might need more powerful drugs or perhaps to start them sooner or to be monitored more frequently than someone with less inflammation. If remission is the goal, the patient and the provider need to be on the same page about what that means.

Ideally, I tell my patients that for them, remission might be little or no pain, no joint swelling, good sleep, improved energy, and the ability to resume their everyday activities. RA is a diverse disease that affects patients in many different ways. So it's important to get their perspective. Some are comfortable with low disease activity and unwilling to increase their medication to get any further benefit. Others are willing to escalate their care until they achieve remission, if possible.

Treat-to-target may be effective because it focuses attention on a specific remission-based goal and encourages change in a treatment that isn't working to get you there. Having said that, many factors can influence the chances of success.

Studies have shown that the treat-to-target plan results in sustained remission for those with early RA, but can also be effective for those with established or long-standing RA. Probably the most important factor in success is early diagnosis coupled with aggressive treatment. Having low disease activity levels at the start of treatment is also a predictor of being able to reach and maintain remission. Being negative for two important criteria of RA, the rheumatoid factor and the anti-cyclic citrullinated peptide antibody, has been associated with increased chances of realizing remission.

Combined with a treat-to-target approach, a shift in strategy over the last several years that includes earlier use of disease-modifying drugs, or DMARDs, and new classes of biologic medications have greatly improved outcomes. Please join me next time, when we explore the range of medications now available to treat RA.