What is the best target in a treat-to-target strategy in rheumatoid arthritis? Results from a systematic review and meta-regression analysis

Abstract

ObjectivesA treat-to-target (T2T) strategy has been shown to be superior to usual care in rheumatoid arthritis (RA), but the optimal target remains unknown. Targets are based on a disease activity measure (eg, Disease Activity Score-28 (DAS28), Simplified Disease Activity Indices/Clinical Disease Activity Indices (SDAI/CDAI), and a cut-off such as remission or low disease activity (LDA). Our aim was to compare the effect of different targets on clinical and radiographic outcomes.MethodsCochrane, Embase and (pre)MEDLINE databases were searched (1 June 2022) for randomised controlled trials and cohort studies after 2003 that applied T2T in RA patients for ≥12 months. Data were extracted from individual T2T study arms; risk of bias was assessed with the Cochrane Collaboration tool. Using meta-regression, we evaluated the effect of the target used on clinical and radiographic outcomes, correcting for heterogeneity between and within studies.Results115 treatment arms were used in the meta-regression analyses. Aiming for SDAI/CDAI-LDA was statistically superior to targeting DAS-LDA regarding DAS-remission and SDAI/CDAI/Boolean-remission outcomes over 1–3 years. Aiming for SDAI/CDAI-LDA was also significantly superior to DAS-remission regarding both SDAI/CDAI/Boolean-remission (over 1–3 years) and mean SDAI/CDAI (over 1 year). Targeting DAS-remission rather than DAS-LDA only improved the percentage of patients in DAS-remission, and only statistically significantly after 2–3 years of T2T. No differences were observed in Health Assessment Questionnaire and radiographic progression.ConclusionsTargeting SDAI/CDAI-LDA, and to a lesser extent DAS-remission, may be superior to targeting DAS-LDA regarding several clinical outcomes. However, due to the risk of residual confounding and the lack of data on (over)treatment and safety, future studies should aim to directly and comprehensively compare targets.PROSPERO registration numberCRD42021249015.

Rheumatoid arthritis knowledge gap and intervention in Nigeria study

“…This knowledge gap highlights the need for updated education on recent advances in RA diagnosis, emphasizing the importance of early diagnosis and treatment to achieve remission in early RA and low disease activity in established cases. 27 A significant knowledge deficit was also observed in the investigation and treatment of RA. More than half of the respondents were unaware of the classification criteria for RA, and a similar proportion did not know that the rheumatoid factor is not definitive for diagnosis, believing that RA can be diagnosed without serology tests.…”

“…It is concerning that 9 out of 10 family physicians believe that RA is characterized by joint deformities, indicating that RA may not be considered until deformities develop. This knowledge gap highlights the need for updated education on recent advances in RA diagnosis, emphasizing the importance of early diagnosis and treatment to achieve remission in early RA and low disease activity in established cases 27 …”

Harmonizing Medicine and Surgery in the Pursuit of Boolean Remission: A Rheumatological Magnum Opus

“…Patients in remission typically require fewer healthcare resources, including medications, hospitalizations, and surgeries [ 26 ]. This reduction in healthcare utilization not only lowers healthcare costs but also allows patients to return to work and daily activities, contributing to their economic well-being [ 27 ].…”

Long-term Efficacy and Safety Following Switch Between Upadacitinib and Adalimumab in Patients with Rheumatoid Arthritis: 5-Year Data from SELECT-COMPARE

“…Clinical remission is widely accepted as the main therapeutic target in RA, with low disease activity (LDA) as a viable alternative in patients who are unable to achieve remission. As a result of the complexity of the disease, patients with RA may require multiple trials of medications with different mechanisms of action (MoAs) to achieve their treatment goal [ 3 – 6 ]. However, despite the number of currently approved advanced therapies with different MoAs available for patients with RA, including bDMARDs, multiple clinical trials and post-marketing reports [ 2 , 7 – 10 ] have shown that a minority of patients achieve remission or LDA when assessed using the Clinical Disease Activity Index (CDAI) or the Simplified Disease Activity Index, metrics favored by the American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology (EULAR) for assessing disease activity in RA [ 3 , 11 , 12 ].…”