2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
(Part 6)
We continue with our discussion of the treat-to-target modality in the management of rheumatoid arthritis (RA).
A treat-to-target approach is vastly recommended by experts over usual care for patients who have not been previously treated with (biologic Disease Modifying Anti Rheumatism Drugs) bDMARDs or (targeted synthetic) tsDMARDs.
This particular recommendation is given to dose optimization of methotrexate and to the addition of DMARDs if needed. The recommendation is deemed to be strong even if there is a low-certainty piece of evidence due to the known importance of systematic monitoring and adjustment of treatment to lower the incidence of inflammation to prevent joint damage, as well as other long-term effects including cardiovascular disease and possible onset of osteoporosis.
The treat-to-target approach may be recommended in certain conditions over usual care for patients who may have not experienced a so successful response to bDMARDs or tsDMARDs.
This particular recommendation is deemed as conditional due to unknown incremental benefits of treat-to-target over usual care given to RA patients.
The usual care refers to the employed common practice patterns, which consist of adjustment of treatment based on shared decision-making, although it is, at times, without systematic monitoring of disease activity using validated metric to reach a certain identified target.
Moreover, it is also important to consider the number of remaining available treatment options, the impact of non-inflammatory causes of pain, co-morbidities, and/or damage on the accuracy the disease activity, and the patient’s limits that may have an impact on the treat-to-target treatment modality.
There is a minimal up front treatment goal for low disease activity which is recommended with some conditions over a goal of remission from RA.
The target of low disease activity is ideal as remission using a certain criteria may not be the outcome for many patients.
Likewise, the expert panel emphasized that being unable to reach a certain target could be stressful to some patients. It is best to aim for low disease activity and moving towards a goal of disease remission. However, goals of the treatment should be periodically reassessed and tailor-fit to patient’s needs when possible.
This particular recommendation can be touted as conditional as remission is a reasonable goal for patients with early disease and minimal exposure to bDMARDs and tsDMARDs. Moreover, the patient’s preferences play a significant role in this kind of treatment decision.
Let us focus our discussion next week on the modification of DMARDS as a modality to treat RA.