The concept of treat-to-target (T2T) can be defined as selecting a goal before treatment starts – such as a level of low disease activity or a specific reduction in the number of painful or swollen joints – then monitoring the patient closely, and adjusting or adding medication if that target is not reached within a given time frame.
By contrast, in routine care (RC), the physician adjusts medication based on his or her own clinical judgment.
A number of previous studies, including the DREAM trial, have shown that treat-to-target is superior to routine care in patients with early RA. The present study is the first one to show this strategy beats routine care in patients with longstanding RA that is active.
In this study out of Canada, called the Optimization of Adalimumab Randomized Trial (OART), 308 patients with established, active RA were randomized to one of three strategies: routine care (RC), treatment to a disease activity score (called DAS28) of less than 2.6, or treatment to a swollen joint count of 0 (SJC 0).
All patients were treated with a combination of adalimumab (Humira), a TNF inhibitor; traditional disease-modifying antirheumatic drugs (DMARDs) such as methotrexate; nonsteroidal anti-inflammatory drugs (NSAIDs); and/or oral or injectable steroids. Patients could see their doctor as often as the doctor deemed necessary, but visits were recommended every six months after the initial visit. Additionally, visits were recommended for patients in the two targeted groups, at months 2, 4 and 9.
The average time to achieve remission – defined as a DAS28 score of less than 2.6 – was faster in the two targeted groups than in the RC group: 13.7 months in the RC group, compared with 12.1 months for the DAS28 group and 12 months for the SJC 0 group.
The dropout rate was significantly higher in the RC group (52.3 percent) compared with the DAS28 group (27 percent) and the SJC 0 group (22 percent), suggesting that patients preferred to stay on therapy in both T2T groups.
“This is the first trial to show that even in established RA treated with a specific biologic agent, patients will get into a low disease state faster and are more likely to remain on their biologic drug if doctors are treating to a target rather than performing usual care,” says lead study author Janet Pope, MD, professor of medicine and chair of the division of rheumatology with the University of Western Ontario Schulich School of Medicine & Dentistry, in Canada.
The study, however, didn’t show which target was better – a DAS28 score below 2.6 or a swollen joint count of zero – but it did show that selecting a target and adjusting medication and dosing according to whether that target was reached, relieves symptoms of RA faster and is more likely to keep patients on their treatments than a strategy of routine care.
Dr. Pope says it is possible that doctors who treat to a specific target may make more changes in the therapies the patient is taking, whereas doctors who provide routine care may not make as many. These adjustments are what may lead to improved outcomes.
“The good news is that with a treating-to-target philosophy, we can use likely any drug or treatment more effectively and optimize the benefit of treatment,” she says.
Stanley B. Cohen, MD, a clinical professor in the department of internal medicine at the University of Texas Southwestern Medical School in Dallas, says the study provides support for the effectiveness of T2T. “This is the wave of the future in rheumatology,” Dr. Cohen says. “Patients who had their therapy modified to active disease as determined by exceeding a specific target of low or minimal disease activity were more likely to continue treatment with adalimumab than patients treated with routine care. The reason for this is not entirely clear.
“The first step is to make sure that rheumatologists routinely measure disease activity using any scale. The next step is to make treating to a target the standard of care,” he says.