TICOSPA - Does Treat to Target Work in Spondyloarthritis? Save

Tight-control or treat-to-target (T2T) strategy is advocated in several diseases, but the recent TICOSPA trial in axial spondyloarthritis (axSpA) showed that T2T was not superior to usual care (UC).

This prospective, randomised, open, 12 month in biologic-naive, patients with active axSpA (ASDAS score ≥2.1) were randomized to either: (1) T2T  with visits every 4 weeks and treatment escalation if ASDAS <2.1; or (2) Usual Care visits every 12 weeks with treatment at the rheumatologist’s discretion. The primary endpoint was ASAS-Health Index (ASAS-HI) improvement ≥30% improvement.

A total of 160 axSpA patients were enrolled ((disease duration 3.7 years) with baseline ASDAS of 3.0 and ASAS-HI of 8.6.  Week 48 outcomes were:

• ASAS-HI ≥30%: 47.3% in T2T vs 36.1% in UC (non-significant).
• ASDAS LDA: 77% T2T vs 30% UC (p<0.01)
• ASAS40: 52% T2T vs 35% UC (p<0.01)
• Secondary efficacy outcomes: some were better for T2T (ASAS LDA, ASAS40, ASAS20, BASDAI50), other outcomes were not significantly different (MD global, CRP, BASFI, EQ5D-5L, ASAS-NSAID score)
• Safety was similar in both arms.

Although biologics were used more in the T2T arm (56.2% vs 27.2%), T2T resulted in an additional 0.04 QALY, and saved €472 compared with UC.

Unlike other T2T trials in rheumatology (TICORA, TICOPA) that chose a primary endpoint that was disease activity-related, the current TICOSPA trial oddly chose a main outcome that was the consequence of disease activity, in this case a specific functional health outcome, the ASAS-HI. 
Although T2T therapy did not achieve its primary goal in this trial, many secondary efficacy outcomes favored T2T over usual care and with healthcare cost advantage, T2T should be advocated in axSpA patients.