Treat-to-Target in Rheumatology – Evolution of the Concept

Neeraj Jain DNB, FACR, FRCP (Edin)
Professor, GRIPMER
Senior Consultant, Department of Rheumatology & Clinical Immunology,Sir Ganga Ram Hospital, New Delhi

How did the concept arise?

The treatment options as well as strategies for the management of rheumatological diseases have drastically changed over the last 2-3 decades. With the advent of biologics as well as the newer small molecules, it has lately been possible to achieve true remission among many patients. Treatment to achieve a target level of a variable known to be associated with worse disease outcomes, similar to what is seen in chronic diseases such as diabetes and Hypertension was realized in rheumatology too. The Treat to Target (T2T) concept was first introduced in 2009 by the UK’s NICE committee suggesting monthly evaluation of inflammatory markers and disease activity until the disease was controlled or has reached a target level previously agreed upon with the person with Rheumatoid Arthritis (RA). The committee itself agreed that modifications might be required on a case-to-case basis determined by individual targets, demographic parameters, or the presence of comorbidities. The target is not always to achieve remission; even achieving low disease activity in difficult or longstanding cases can be a reasonable target. Importantly it engages the patient in a discussion about their own goals for treatment.

How has the concept evolved?

T2T concept is not limited to RA; It has evolved in other rheumatological conditions including Spondyloarthropathy, Systemic lupus erythematous, Psoriasis, etc. The concept starts with setting a specific, well-defined, predetermined, achievable, and measurable target followed by intervening with therapeutic options to achieve the same. The most important aspect is to modify or fine-tune the intervention at specified regular intervals if the desired outcome is not achieved.

Initially, T2T strategy faced multiple challenges as it was confused between being a fact, fiction, or hypothesis. But multiple randomized controlled trials proved its significance, and it forms the basis of all current guidelines and recommendations.

What are the implications for the care-givers and the patients?

A huge evidence-practice gap exists regarding the implementation of T2T strategy. Multiple reasons include different practice patterns, variations in awareness and agreement with the concept per se. A tailored T2T strategy in line with the local healthcare facilities and practices is important. Physicians belonging to different schools of thought have an inclination either towards a tight control or a casual approach over T2T strategy in terms of frequency of monitoring as well as rapid changes in treatment options. To date, the data on the degree to which T2T is employed by physicians are scarce.Though some elements of T2T are widely used, full implementation still remains a challenge. Knowledge gaps need to be addressed related to the selection of the right target and frequency of monitoring for each patient in an evidence-based manner.

Suggested reading:

  • Van Vollenhoven, R. Treat-to-target in rheumatoid arthritis — are we there yet? Nat Rev Rheumatol 2019; 15: 180–186.
  • Solomon DH, et al. Review: Treat to target in rheumatoid arthritis: fact, fiction, or hypothesis? Arthritis Rheumatol. 2014; 66(4):775-82.