Reflecting on recent progress in the treatment of inflammatory arthritis, I am especially gratified by the concept of treat to target (T2T). T2T places our specialty smack in the mainstream of modern medicine. After all, much of internal medicine is based on T2T, whether the target is blood pressure, glycosylated hemoglobin (hemoglobin A1C) levels, or the international normalized ratio (INR). As a scientist, I like numbers, and I welcome them to our specialty. The more the better. Interestingly, some important clinical measures, such as the pulse rate or respiratory rate, have never been established as therapeutic targets because the range is large, and circumstances dictate where in the range the sweet spot lies. Of course, age is never explicitly a target for efforts at prevention or treatment—beyond it reaching a number as large as possible—but we hope it is at least three score and ten.
As those of you who are regular readers of The Rheumatologist (TR) know, T2T has long been a theme of our publication, and we have been pleased to publish articles on the history of the investigators who established the metrics that are currently the foundation of T2T. Thus, TR has recounted the seminal contributions of investigators such as the late John Sharp, Piet van Riel, Josef Smolen, Jim Fries, and Ted Pincus, among others. Without the pioneering work of these inspired individuals, rheumatology would not have targets at which to aim. In chronicling the story of outcome measures, we have not forgotten our lab-based colleagues. We already have started a series on outstanding scientists like Eng Tan, who founded modern serology and made testing of antinuclear antibodies an essential part of rheumatologic evaluation.
For many years, I have been an enthusiast of the Disease Activity Score (DAS) and use it regularly when I see patients and teach house officers and fellows, constantly Googling “DAS calculator,” only to find a site established by a company with a biologic in its portfolio. The product was not a big seller, but the site remains available and is quite nifty. I like to punch in the numbers from my exam and see how close to target we currently are.
DAS Versus Patient-Reported Symptoms
Recently, along with a resident, I saw a patient whose DAS left me baffled. As is the practice in our teaching clinic, the house officer sees the patient first and presents the case to me for preliminary discussion. We then see the patient together, and I do my own history and physical exam. The resident that day was a bright young man, aspiring to a career peering though a colonoscope at colonic mucosa although, to his credit, he was interested in learning more rheumatology because of the association of inflammatory bowel disease with arthritis and the frequent use of tumor necrosis factor blockers for patients with active Crohn’s disease.
