Treat-to-Target in Rheumatology practice in India

Ashok Kumar MD FRCP
Clinical Director & Head, Department of Rheumatology, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, New Delhi

What are the major challenges in India?

There are 2 major challenges when we apply the T2T paradigm in the Indian setting: patients presenting late to the rheumatologists and their poor compliance with treatment. There is a widespread public perception that modern medicine (‘allopathy’) results in serious adverse effects. So, they first try alternative systems of medicine and often end up losing the precious window of opportunity. When they do seek modern medicine, there is a strong urge to prematurely reduce the dose of DMARDs or stop them altogether (sometimes at the behest of chemists- `Why are you taking anticancer drugs?). Often their irregular visits to rheumatology clinics are prompted by severe exacerbations of the disease and not as planned visits.

What are the practice-setting-specific challenges?

In a government hospital setting, many patients belong to poor socioeconomic backgrounds. Often the family loses a day’s wages besides incurring travel and other expenses on each hospital visit. They may find it impossible to make frequent visits. Add to this the inability to afford the cost of medications! Result? T2T becomes irrelevant! Besides, patient numbers may be too large to allow frequent visits.

In corporate hospitals/private clinics, the ‘well-to-do’ patients pose a different kind of challenge: many patients, despite a good understanding of the nature of the disease, will not keep their clinic appointments. They are strangely at peace with suboptimal disease control and will turn up for clinic visits at their convenience. One wonders whether this reflects laziness, a genuine lack of time, or a means of economizing on treatment expenses.

What should be the feasible and practical approach in India?

Successful implementation of T2T strategy is feasible in India only with good patient education on the first visit itself. Time invested in educating the patient about the crucial importance of regular clinic visits and using the T2T approach will go a long way. SDAI and CDAI are more stringent indices compared to DAS28 and should be preferred in the clinic. No calculators are needed for these indices because a simple sum of all parameters is needed. What should one do in longstanding but `active’ RA? Again, emphasis on regular clinic visits, with zero tolerance for signs of synovitis, leading to necessary treatment escalation is the key. Astute clinicians would carefully avoid escalating treatment when fibromyalgia (not flare) is the real issue.

Suggested reading:

  1. Drosos AA, Pelechas E, Voulgari PV. Treatment strategies are more important than drugs in the management of rheumatoid arthritis. Clin Rheumatol 2020;39:1363-1368.
  2. Nikiphorou E, Ibrahim F, Scott DL. Rheumatoid Arthritis Real-world Management Over 20 Years. J Rheumatol 2021;48:960–2.