Optimisation of a treat-to-target approach in rheumatoid arthritis: strategies for the 3-month time point

Abstract

The 3-month time point is a critical decision point. Not achieving minor responses at 3 months makes reaching of the treatment target at 6 months highly unlikely, while reaching major responses is highly predictive of reaching the treatment target.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update

“…In 2010, the notion ‘as soon as possible’ was also part of this item98 and in the current discussion it was specifically decided to mention that the treatment target should be rapidly attained rather than aiming to achieve it in a more distant future. Indeed, there is sufficient evidence that most patients who do not attain significant improvement within 3 months, or do not achieve the treatment target within 6 months, will not reach the desired state subsequently31 99–101; exceptions pertain to those patients whose disease activity has been reduced to a level close to the treatment target.…”

“…Improvement by 3 months refers to the fact that if a minimal change is not achieved, there is only a low likelihood of reaching the treatment target. Thus, a change to a better disease activity state should be seen at 3 months or a relative improvement, pertaining to at least 50% improvement in activity by a composite score, at that point in time, in order to have a considerable chance of reaching the target 31 100 112 113. Of note, adjustment of therapy includes the optimisation of MTX (or other csDMARD) dose or route of administration,4 or intra-articular injections of GC in the presence of one or few residual active joints, and refers to a change of drugs only if these measures have not been successful or are not appropriate.…”

Application of treat-to-target principles in patients with early rheumatoid arthritis in routine clinical practice in Central-Eastern Europe

“…Thus, between RA diagnosis (a mean of 5.5 months before the baseline visit) and the last attended study visit (~12 months after baseline), treatment targets were set for 98.6% of patients. This high proportion of targets early in the disease course is encouraging since pooled analyses of clinical trials have shown that achieving minor responses at 3 months is critical for further positive outcomes [27]. As regards other T2T principles, treatment targets had been discussed and agreed upon at baseline for nearly all patients (96.6%, T2T-AS).…”

Treat-to-target as an approach in inflammatory arthritis

“…Therefore, early prediction of 6-month outcome is desirable. Recently, it could be shown, that about 80% improvement of clinical disease activity by CDAI or SDAI at 3 months allows achieving low disease activity or remission at 6 months in the vast majority of patients [64]. If this extent of improvement is not attained, treatment changes may be considered already at this 3-month time point.…”