Treat-to-target is a widely used approach for rheumatoid arthritis, in which rheumatologists prescribe treatments to reach established benchmarks of disease activity.1 Is it time for a similar approach for fibromyalgia treatment, even though its pathogenesis, disease-activity measures and treatment algorithms are less well understood?
Three fibromyalgia researchers present their case in a new paper, “Treat-to-Target Strategy for Fibromyalgia: Opening the Dialogue.”2 Challenges include validation of existing diagnostic and treatment algorithms, validation of individualized vs. universal treatment strategies and consensus on criteria to assess the effects of treatment.
“A treat-to-target strategy requires very well-defined criteria, but in fibromyalgia, these are not definite,” says Mary-Ann Fitzcharles, MB, ChB, professor of medicine at McGill University Health Centre in Montreal, Quebec, Canada. Her co-authors are Winfried Hauser, MD, medical director, Psychosomatic Clinic of Internal Medicine at Klinikum Saarbrücken in Saarbrücken, Germany, and Daniel J. Clauw, MD, director of the Chronic Pain and Fatigue Research Center at the University of Michigan Medical School in Ann Arbor, Mich.
The ACR endorsed preliminary diagnostic criteria for fibromyalgia, which were first published in 2010 and modified in 2011, but there are no established benchmarks for disease activity.3,4
Why We Need Treat to Target
Fibromyalgia is a prevalent disease affecting about 2% of the global population. Its often long-lasting symptoms affect quality of life and function, and it may impact both direct and indirect health costs.5-7 “About 20–30% of patients with defined inflammatory joint disease also have underlying fibromyalgia as an important component,” says Dr. Fitzcharles.
Development of a treat-to-target strategy should include clear disease definition, knowledge of long-term consequences of inadequate treatment, effects of and duration of treatment, defined meaningful outcome measures and accepted response criteria, say the authors. Fibromyalgia’s pathogenesis and disease mechanisms are still not well understood, and precise diagnosis may be elusive and delay treatment, says Dr. Fitzcharles. “You have to be sure you have a well-defined condition and must have universally accepted diagnostic criteria,” says Dr. Fitzcharles. Some fibromyalgia experts debate the ACR-endorsed criteria, possibly because widespread pain, the hallmark symptom, may vary greatly in intensity over time and be highly variable between patients.8 Patients may express somatic symptoms and mood issues very differently, making them hard to measure among a larger population.9
In fibromyalgia, weighting each patient’s symptoms may reflect global health status more effectively than using generic measurements, the authors say.10
“We need international acceptance of the diagnostic criteria for this condition. We need to know who we are treating,” says Dr. Fitzcharles. “We need long-term epidemiological studies to give us a good idea of what happens to these patients and a clearer understanding of patient outcomes.”