Australian rheumatologists need to follow ‘treat to target’ guidelines in more than 80% of a patient’s consultations to obtain optimal responses in early rheumatoid arthritis, real-life clinical data shows.

The study led by a team of rheumatologists from the Royal Adelaide Hospital concluded that ‘high’ physician compliance, maximising the likelihood of remission, required adherence to ‘treat to target’ (T2T) recommendations in >80% of visits to meet DAS28 remission criteria.

The proportion increased to >90% of visits if their patients were to meet simplified or clinical disease activity index (SDAI/CDAI) remission criteria.

Writing in the International Journal of Rheumatic Diseases, the research team said the current goal of RA treatment is to achieve remission for patients presenting with early disease, or low disease activity for patients with established disease.

They analysed physicians’ decisions in 3,078 clinic visits by 149 patients who were initially DMARD-naive and were then followed for 3 years.

Using doctors’ letters, medical records and patients’ reports of their treatment, they examined whether medication dose were escalated according to treatment guidelines when patients were not experiencing significant toxicity.

Treatment decisions complied with T2T protocols in 76.1% of visits, they discovered.

“Fundamental to the T2T approach is frequent assessment of disease activity and appropriate DMARD modifications,” they said.

However, they recognised the practical challenges of the approach.

“T2T is more complex than routine clinical care, and implementation in daily practice is not without obstacles.”

Factors influencing dose escalation included the heterogeneous nature of the disease; the physician’s beliefs; the patient’s condition, preferences and comorbidities; medication-related factors such as toxicity and contraindications; and logistic issues.

“100% physician compliance with a T2T protocol is unrealistic due to these barriers,” they said.

Although the study found a highly significant association between doctors’ compliance with T2T protocols and 3-year outcomes, it could not necessarily be interpreted as a cause-effect relationship.

“While it is intuitive to think that better physician compliance will lead to better outcomes,

it is also possible that more responsive disease will provide fewer opportunities for non-compliance than recalcitrant RA,” they said.

“Furthermore, simply stating that compliance should be increased ignores the relatively large incidence of dose-related DMARD side effects and the inevitable (and justified) non-compliance that occurs with these patients.”