Updated RA Treat-to-Target International Recommendations Save

In 2010, Smolen and a group of international rheumatologists developed a series of recommendations addressing the concept of treat-to-target (T2T) in the management of rheumatoid arthritis (RA).  While these guidelines defined the target (LDAS) and manner of assessment (that would include quantification of synovitis), these were largely consensus based.

In 2014, the authors reconvened and examined their T2T recommendations with the goal of incorporating stringent, direct evidence over expert opinion, wherever possible. They have published their updated recommendations, which are largely unchanged and incorporates the patient into the decision-making process.  These are the four overarching principles and 10 recommendations put forth.

Four overarching principles:

1. The treatment of RA must be based on a shared decision between patient and rheumatologist.
2. The primary goal of treating patients with RA is to maximize long-term health-related quality of life through control of symptoms, prevention of structural damage, normalization of function and participation in social and work-related activities.
3. Abrogation of inflammation is the most important way to achieve these goals.
4. Treatment to target by measuring disease activity and adjusting therapy accordingly optimizes outcomes in RA.

Rheumatoid arthritis Treat-to-Target recommendations:

1. The primary target for treatment of RA should be a state of clinical remission.
2. Clinical remission is defined as the absence of signs and symptoms of significant inflammatory disease activity.
3. While remission should be a clear target, low-disease activity may be an acceptable alternative therapeutic goal, particularly in long-standing disease.
4. The use of validated composite measures of disease activity, which include joint assessments, is needed in routine clinical practice to guide treatment decisions.
5. The choice of the (composite) measure of disease activity and the target value should be influenced by comorbidities, patient factors and drug-related risks.
6. 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.
7. Structural changes and functional impairment and comorbidity should be considered when making clinical decisions, in addition to assessing composite measures of disease activity.
8. Until the desired treatment target is reached, drug therapy should be adjusted at least every three months.
9. The desired treatment target should be maintained throughout the remaining course of the disease.
10. The rheumatologist should involve the patient in setting the treatment target and the strategy to reach this target.