Goal-Directed Therapy for Rheumatoid Arthritis: 2010 Recommendations
Goal-Directed Therapy for Rheumatoid Arthritis: 2010 Recommendations
Smolen JS, Aletaha D, Bijlsma JW, et al; for the T2T Expert Committee
Ann Rheum Dis. 2010 Mar 9; [Epub ahead of print]
Multiple studies over the past few years have evaluated the utility of treating rheumatoid arthritis (RA) on the basis of disease activity, as determined by defined measures of disease activity, such as the Disease Activity Score (DAS). These studies have largely shown that treating RA to meet a goal disease activity level results in improved outcomes. For example, in the Tight Control of Rheumatoid Arthritis (TICORA) study, patients whose RA therapy was escalated every 3 months to reach a goal DAS of < 2.4 had better outcomes than those not treated with goal-directed therapy. To provide widespread recommendations for the goal-directed approach for RA treatment, in 2008 the European League Against Rheumatism (EULAR) established an "Expert Committee" designed to provide guidance for RA treatment to a "target" of disease control. Initially, a steering committee performed a literature review to determine a consensus for treatment targets for RA. Recommendations following from this review were then presented to RA experts (N = 60, including patients) from multiple countries, and recommendations for treatment were scored for level and strength of evidence. Finally, the recommendations were voted on and approved for distribution. Of note, the final literature review of this Committee included 19 papers and 5 abstracts (pending list publication).
The Expert Committee made a total of 10 recommendations for the treatment of RA, and these are condensed as follows. The main goal for RA treatment should be remission, which was defined as the absence of signs/symptoms of inflammatory disease activity, although the Committee acknowledges that the instruments used to determine remission may differ (such as the American College of Rheumatology's criteria, or the DAS) and did not recommend any one instrument. The Committee also acknowledged that low disease activity may be acceptable in some instances. They also recommended that changes in therapy be made during active disease at least every 3 months, and these changes should be made on the basis of composite measures of disease activity, which include joint assessment, but not necessarily inflammatory markers. Such measures included the DAS with a 28-joint count (DAS28) and the Simplified or Clinical Disease Activity Index (SDAI or CDAI). The Committee did not recommend one measure over another, and acknowledged that each measure may be influenced by a variety of factors. They also recommended that once reached, treatment target should be maintained, and that structural changes and functional impairment should be considered when making decisions about therapy -- perhaps to avoid escalation of therapy in a patient who may have irreversible symptomatic damage that would not benefit from more aggressive immunotherapy. Also of note, the Committee stated that overriding this treatment-to-target approach were guiding principles of shared decision-making between patients and rheumatologists, with the ultimate goal of treatment being to maximize health-related quality of life by controlling inflammation.
These recommendations represent the culmination of considerable discussion in regard to the treatment of RA. Certainly, given the data available to date, it seems prudent for those who treat RA to aim for disease remission and base therapeutic changes on standardized measures of disease activity. However, going forward, it will be of use to know which measures of disease activity perform best, and to clarify which treatment regimens may allow for best control of disease. Finally, the study authors mentioned that remission may be achieved in the majority of patients with early RA, although the time period defining early RA is not discussed. As such, in the near future, the time-point in the course of RA at which goal-directed therapy is instituted may be a crucial factor in reaching disease remission.
Abstract
Treating Rheumatoid Arthritis to Target: Recommendations of an International Task Force
Smolen JS, Aletaha D, Bijlsma JW, et al; for the T2T Expert Committee
Ann Rheum Dis. 2010 Mar 9; [Epub ahead of print]
Introduction
Multiple studies over the past few years have evaluated the utility of treating rheumatoid arthritis (RA) on the basis of disease activity, as determined by defined measures of disease activity, such as the Disease Activity Score (DAS). These studies have largely shown that treating RA to meet a goal disease activity level results in improved outcomes. For example, in the Tight Control of Rheumatoid Arthritis (TICORA) study, patients whose RA therapy was escalated every 3 months to reach a goal DAS of < 2.4 had better outcomes than those not treated with goal-directed therapy. To provide widespread recommendations for the goal-directed approach for RA treatment, in 2008 the European League Against Rheumatism (EULAR) established an "Expert Committee" designed to provide guidance for RA treatment to a "target" of disease control. Initially, a steering committee performed a literature review to determine a consensus for treatment targets for RA. Recommendations following from this review were then presented to RA experts (N = 60, including patients) from multiple countries, and recommendations for treatment were scored for level and strength of evidence. Finally, the recommendations were voted on and approved for distribution. Of note, the final literature review of this Committee included 19 papers and 5 abstracts (pending list publication).
Study Summary
The Expert Committee made a total of 10 recommendations for the treatment of RA, and these are condensed as follows. The main goal for RA treatment should be remission, which was defined as the absence of signs/symptoms of inflammatory disease activity, although the Committee acknowledges that the instruments used to determine remission may differ (such as the American College of Rheumatology's criteria, or the DAS) and did not recommend any one instrument. The Committee also acknowledged that low disease activity may be acceptable in some instances. They also recommended that changes in therapy be made during active disease at least every 3 months, and these changes should be made on the basis of composite measures of disease activity, which include joint assessment, but not necessarily inflammatory markers. Such measures included the DAS with a 28-joint count (DAS28) and the Simplified or Clinical Disease Activity Index (SDAI or CDAI). The Committee did not recommend one measure over another, and acknowledged that each measure may be influenced by a variety of factors. They also recommended that once reached, treatment target should be maintained, and that structural changes and functional impairment should be considered when making decisions about therapy -- perhaps to avoid escalation of therapy in a patient who may have irreversible symptomatic damage that would not benefit from more aggressive immunotherapy. Also of note, the Committee stated that overriding this treatment-to-target approach were guiding principles of shared decision-making between patients and rheumatologists, with the ultimate goal of treatment being to maximize health-related quality of life by controlling inflammation.
Viewpoint
These recommendations represent the culmination of considerable discussion in regard to the treatment of RA. Certainly, given the data available to date, it seems prudent for those who treat RA to aim for disease remission and base therapeutic changes on standardized measures of disease activity. However, going forward, it will be of use to know which measures of disease activity perform best, and to clarify which treatment regimens may allow for best control of disease. Finally, the study authors mentioned that remission may be achieved in the majority of patients with early RA, although the time period defining early RA is not discussed. As such, in the near future, the time-point in the course of RA at which goal-directed therapy is instituted may be a crucial factor in reaching disease remission.
Abstract