‘We should aim for at least 50% improvement in disease activity by three months.’ —Josef S. Smolen, MD
Treat to Target
In many cases, however, physicians do not treat patients with RA to target. Patients may, for example, initially be prescribed methotrexate, and insufficient responders are then prescribed alternative disease-modifying anti-rheumatic drugs. This process can take years, during which time the patient may never achieve remission. “I believe thousands, if not millions, of RA patients in the world are managed inadequately,” said Dr. Smolen.
He then described the 2014 algorithm to treat RA to target, noting the importance of reaching remission or low disease activity. He explained the best way to achieve this goal is to adapt therapy in a timely fashion. This means calculating a composite measure of disease activity every one to three months. “Given the fact that we have many therapies available now, … we should be able to rapidly adapt therapy of patients who do not reach a response,” he said.
Predictors of Long-Term Response
Dr. Smolen reminded the audience that response at three months from treatment initiation predicts long-term response. Thus, the way to the target is also a target.
“We should aim for at least 50% improvement in disease activity by three months. … Anything else is just too low. … By six months, the target should be reached, or the drug or treatment strategy switched,” he said.
Dr. Smolen also counseled the gathered rheumatologists to forget personalized medicine and focus on abating disease activity with the goal of getting patients into remission.
Unfortunately, Dr. Smolen noted, although remissions increase with a treat-to-target approach, approximately 25–30% of patients with RA are refractive to treatment, and their inflammation remains consistently active. At least two factors seem to contribute to this treatment refractory state: time to treatment and high disease activity. The two factors are interrelated because the longer the disease is untreated, the higher the level of disease activity. “This speaks for early therapy and rapid intervention,” he emphasized.
Dr. Smolen concluded by acknowledging that RA continues to be a chronic disease without a cure. He suggested the best approach is early intervention using treat to target. Such an approach makes it possible to achieve remission in an unprecedented proportion of patients, prevent joint damage and minimize the progression of RA.
Lara C. Pullen, PhD, is a medical writer based in the Chicago area.
