Treat-to-target Approach Needed for Rheumatoid Arthritis

A study published in Clinical Rheumatology identified a significant need for a treat-to-target approach in patients with rheumatoid arthritis (RA).

“For [RA] patients who have active disease despite initial [conventional synthetic disease-modifying anti-rheumatic drug] monotherapy, guidelines recommend treatment advancement to a combination of csDMARDs and/or use of biologics or Janus kinase inhibitors (JAKi). In clinical practice, it is common for patients treated with csDMARDs to remain in a moderate-to-high disease state without treatment advancement to a biologic or targeted synthetic DMARD,” the study authors wrote, adding that “Patients with RA who remain in a moderate-to-high disease activity state have worse short- and longer-term outcomes (increased pain burden, disability, irreversible joint damage, etc.).”

This study therefore sought to evaluate the burden of disease among RA patients treated with csDMARDs for six months who do not move on to treatment with a biologic or JAKi.

The US Corrona RA Registry was queried for patients enrolled from June 1, 2014, through Jan. 30, 2018, based on the following eligibility criteria: six months of continuous csDMAR monotherapy, moderate to high disease activity, biologic naïvety, and at least one completed follow-up visit.

Final analysis included 409 patients (mean [SD] age, 65.9 [12.6] years; mean duration of csDMARD therapy, 407 [221] days). More than half (n = 219, 54%) of the total cohort stayed in moderate-to-high disease activity. These patients were more likely to have swollen (6.1) and tender joint counts (6.8).

During the six-month study period, 29% of patients (n = 118) advanced their treatment. Treatment advances included csDMARD dose escalation (n = 55, 13%), initiation of another csDMARD (n = 33, 8%), and initiation of a biologic DMARD (n = 40, 10%). Compared to those who did not advance treatment (n = 291), patients who did were more likely to have younger age, shorter disease duration, higher disease activity, prednisone doses ≥  10 mg, lower EuroQol 5 Dimensions scores, higher Clinical Disease Activity Index (CDAI) higher disease activity measures, and higher reported pain and fatigue levels.

Among patients who did not advance treatment but whose CDAI RA score remained > 10 after six months, the mean age [SD] was 66.6 [12.4] years, csDMARD use duration was 371.8 [202.3] days, and disease duration was 11.4 [11.0] years.

The study authors concluded that “a substantial number of patients with RA continue to be managed with csDMARD monotherapy despite remaining in moderate-to-high disease activity at a 6-month follow-up visit. This indicates that there is considerable need for a treat-to-target approach to care to prevent joint damage and physical disability and maximize long-term health-related quality of life for patients with RA. Furthermore, future studies are warranted to elucidate factors related to the response variation of csDMARD and treatment selection for RA disease.”