Treat-to-target has become the driving paradigm in rheumatoid arthritis treatment. Treating patients has shifted away from traditional metrics of joint damage and towards the individual needs of patients.
“In the contemporary era of protocol-driven medical practices, in which drug reimbursement is often dependent on a restricted set of outcome metrics, the treating physician needs to recognize the aspects of life that most trouble the patient and, when possible, address them with pharmacological and non-pharmacological interventions as appropriate,” write Peter C. Taylor, Ph.D., and Janet Pope, M.D., MPH in a commentary published in the September 1 issue of The Lancet Rheumatology.
Dr. Taylor, of the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at the University of Oxford, and Dr. Pope, chair of rheumatology at St. Joseph's Health Center in London, address advances in rheumatoid arthritis treatment.
They highlight three game changers in treatment.
1) The recognition of the importance of early intervention with disease modifying anti-rheumatic drugs (DMARD).
2) Advances in understanding of the pathobiology of disease and the identification of many potential therapeutic targets.
3) The “recognized importance and implementation of a so-called tight control approach to inflammatory responses, with a view to limiting or even abrogating the many consequences of inflammation.”
The authors suggest that focusing solely on aggressive treatment guidelines with hard endpoints discounts the individual subjective needs of rheumatoid arthritis patients. While prevention of joint damage and deformity in rheumatoid arthritis are often attained with the treat-to-target approach, subjective patient reported outcomes such as fatigue, pain, and mental health effects may negatively impact social interaction, sexual activity, work productivity and overall wellbeing.
A recent observational study by G.A. Bersteeg et al. published in Clinical Rheumatology, showed that the treat-to-target strategy in rheumatoid arthritis led to global improvements not only in disease activity scores but also patient reported outcomes such as functional ability and overall quality of life. While most patients in this observational study reported sustained improvements in bot physical and mental quality of life, nearly one-third did not, pointing to a significant area for improvement.
Patients that remain refractory to disease modifying anti-rheumatic drugs may benefit through assessment of their own reported needs leading to additional management choices aimed at improving their individual perception and quality of life, Drs. Taylor and Pope write. They cite several studies showing that only a minority of patients with rheumatoid arthritis attain and maintain in remission over the long term, however, newer long term observations such as those made by G.A Bersteeg and colleagues show an overall sustained improvement in patient reported outcomes adhering to stringent treat-to-target guidelines.
They cite Sir William Osler, a Canadian Physician and a founding father of Johns Hopkins Hospital in Baltimore (founded in 1889): “The good physician treats the disease but the great physician treats the patient who has the disease.”
Peter C. Taylor and Janet Pope. Treating to target or treating the patient in rheumatoid arthritis? The Lancet Rheumatology. Vol 1, Issue 1, PE8-E10, September 01, 2019
G.A Versteeg, L.M.M. Steunebrink, H.E. Vonkeman, et al. Long-term disease and patient-reported outcomes of a continuous treat-to-target approach in patients with early rheumatoid arthritis in daily clinical practice. Clinical Rheumatology. (2018) 37:1189–1197 https://doi.org/10.1007/s10067-017-3962-5