Treat-to-Target in Rheumatology – A perspective

Senior Consultant Rheumatologist & Clinical Immunologist and Commandant, Command Hospital (AF), Bengaluru

Importance of having measurable Targets in managing rheumatic diseases

“If you can’t measure it, you can’t improve it”

Peter Drucker

If diseases were to be ranked by the quality of measures to monitor that was both easy and accurate to use, Hypertension and Diabetes would be declared the winners. The long-term goal in both illnesses is the prevention of target organ damage (e.g., retinopathy, CAD) which is easily achieved by monitoring a couple of simple parameters (Blood pressure, Blood sugar/ HbA1c). By the same standards, Rheumatic diseases, characterized by remissions and relapses of disease activity with progressive accrual of damage across multiple organ systems, would clearly be among the laggards. Disease activity is the proverbial fire that needs to be kept at zero or bare minimum (remission/LDA) to prevent structural damage, improve functional ability and maximise thelong-term quality of life. An ability to measure the ‘fire’ objectively would enable better management. The TICORA trial proved that T2T achieved higher remission rates and lower subsequent radiographic damage in RA translating to better health-related quality of life and improved physical function. The strategy employed was possibly more important than the actual choice of DMARDs/biologics. Similar results followed in Psoriatic arthritis, Juvenile Idiopathic Arthritis, gout, other Spondyloarthritides and Lupus.

Rheumatology-specific hurdles in defining the targets

The disease activity being multidimensional defies easy definition. The target is not a single parameter but a combination of subjective (e.g.,patient global assessment) and objective dimensions (clinical: SJC, TJC, Lab: ESR/CRP) that serves as a surrogate marker of disease activity. Scientists did combine them in multiple ways. Rheumatoid arthritis alone had over 60 such targets to choose from, some based on simple additions (e.g., CDAI) and others derived by complicated algorithms needing a calculator (e.g. DAS 28).

How do we balance the perspectives of the patient and the clinician?

The application of T2T is not yet widespread and universal. While access to care to rheumatologists remains a dominant reason, even amongst practicing rheumatologists it’s a minority who truly follow a T2T strategy. Many believe that their clinical “gestalt” of a patient’s disease activity is equivalent or superior to a validated disease activity measure and perceive it as a devaluation of their clinical expertise. Patients too sometimes resist T2T. The reasons include fear of altering regimens and new side effects, fear of worsening illness with the change of regimen, and satisfaction with the status quo of mild to moderate disease activity that seemed controllable/ acceptable. While the rheumatologists consider achievement of remission as treatment success, for most patients it is about a holistic sense of well-being. Despite achieving large-scale improvements in disease activity or remission, the same doesn’t translate to patient-reported outcomes like pain, functional disability, and mental well-being. There is a need to balance between improving T2T acceptance among rheumatologists and aligning it with patient expectations. It’s time to redefine T2T strategies by incorporating patient-related outcomes into them with an emphasis on shared decision-making.

Suggested reading:

  1. Ford JA, Solomon DH. Challenges in Implementing Treat-to-Target Strategies in Rheumatology. Rheum Dis Clin North Am. 2019; 45(1) : 101-112.
  2. Schoemaker CG, de Wit MPT. Treat-to-Target from the Patient Perspective Is Bowling for a Perfect Strike. Arthritis Rheumatol. 2021; 73(1) : 9-11.