Rheumatoid arthritis

RA remission a realistic goal with treat-to-target strategy


A treat-to-target strategy for rheumatoid arthritis patients is feasible in real world practice and can achieve results as good as randomised controlled trials, according to rheumatologists in the Netherlands.

Five year outcomes from the Dutch RhEumatoid Arthritis Monitoring (DREAM) study of more than 220 patients show that more than 80% achieved sustained remission at some point during the follow up.

The long term outcomes were based on treating patients to a target of a 28-joint Disease Activity Score (DAS28) of less than 2.6, using a protocol that included stepping up therapy with DMARDs such as methotrexate, sulfasalazine and TNF inhibitors.

Reporting their results in Clinical Rheumatology, the Dutch clinicians emphasised that they came from a real-life cohort of patients with early stages of RA without the strict exclusion criteria and controlled conditions of randomised trials.

“These ‘real-life data’ are of important additional value in the evidence for the effectiveness of a treat-to-target approach in RA patients,” they wrote.

Patients’ functional disability and quality of life improved significantly in the first six months after starting the treat-to-target protocol. Levels of disease activity improved from baseline mean DAS28 scores of 4.93 to 2.49 within 12 months, and remained stable over the five years of follow up.

At 12 months, 63% of patients were in remission and 16% had low disease activity, while 18% had moderate disease activity and 3% remained with high disease activity.

Sustained remission – defined as at least six months with a DAS28 score of less than 2.6 – was achieved by 84% of patients at least once during the follow up. Drug-free remission with the withdrawal of all DMARDs for at least six months, was achieved by 36% of patients at least once during follow up.

The researchers noted that 17% of patients were treated with biologicals, mainly TNF-α inhibitors such as adalimumab and  etanercept. Almost half (48%) of the patients who achieved sustained remission  did so with with DMARD monotherapy while 41% were prescribed DMARD combination therapy.

The researchers said their findings showed that achieving remission in rheumatoid arthritis was a realistic goal in real life practice, despite the known challenges of implementing a treat-to-target strategy for both rheumatologists and their patients

A recent survey of Australian rheumatologists, reported in the limbic, found that about half used the treat to target approach in their practice.

The survey author, Dr Helen Benham a rheumatologist at Princess Alexandria Hospital , Brisbane, told the limbic that the Dutch clinicians were reporting results from RA patients within a protocolised cohort, set up for clinical research that is very different to ‘real-life’ clinical practice settings in Australia.

“Our preliminary data indicates that the majority of Australian rheumatologists agree with the RA treatment to target recommendations and 50% of Australian rheumatologists always or very often use a T2T strategy for RA patients,” she said.

However the survey findings also suggested there were many barriers present to the uptake of RA T2T in Australia, she added.

“Australian Rheumatologists indicate that barriers including lack of time during consultations, poor availability of appointments, difficulty with patient acceptance of the up-titration of medications and lack of rheumatology nurses impede the use of RA treatment to target in everyday practice” said Dr Benham, who is a researcher at The University of Queensland, Translational Research Institute.

A concurrent survey of more than 100 Australian RA patients showed that only 9% were aware of RA T2T but  88% would be willing to try it.

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