DESTIN, Fla. — There are three overarching principals and 10 recommendations rheumatologists should consider when managing the care of patients with rheumatoid arthritis, according to a speaker at the Congress of Clinical Rheumatology Annual Meeting, here.
Daniel Aletaha, MD, MSc, associate professor of medicine at the Medical University of Vienna in Vienna, was part of a task force of rheumatologists, patients and a nurse specialist who assessed and re-evaluated a 2010 systematic literature review on treat-to-target recommendations for rheumatoid arthritis (RA). Levels of evidence, evaluator agreement and strength of recommendations were concluded from the review.
Of the three principals, Aletaha said rheumatologists should “set the clinical target before treatment, determining if there is low disease activity or remission. They should assess care during treatment, deciding when change in therapy is needed.” Rheumatologists should also adjust treatment beyond clinical remission as necessary, Aletaha added.
Treatment options for RA may include synthetic and biological disease-modifying antirheumatic drugs. Approved biological and novel compounds have shown clinical efficacy, but regarding universal treatment of RA, Aletaha said rheumatologists should consider the 10 treat-to-target recommendations.
The recommendations note the primary target for treatment of RA should be a state of clinical remission, defined as the absence of signs and symptoms of significant inflammatory disease activity. Although remission should be a clear target, low disease activity may be an acceptable alternative therapeutic goal, particularly in long-standing disease.
Until the desired treatment target is reached, drug therapy should be adjusted at least every 3 months. Measures of disease activity must be obtained and documented regularly, as frequently as monthly for patients with high or moderate disease activity or less frequently for patients in sustained low disease activity or disease remission. Use of validated composite measures of disease activity, which include joint assessments, is needed in routine clinical practice to guide treatment decisions.
Structural changes, functional impairment and comorbidity should be considered when making clinical decisions, in addition to assessing composite measures of disease activity. The desired treatment target should be maintained throughout the remaining course of the disease, Aletaha said, and the choice of the composite measure of disease activity and the target value should be influenced by comorbidities, patient factors and drug-related risks.
The patient should be appropriately informed about the treatment target, and the strategy planned to reach this target should be under the supervision of the rheumatologist, Aletaha said.
Reaching the therapeutic target of remission or low-disease activity has significantly improved outcomes in patients with RA in recent years, Aletaha said, but he added that understanding the pathogenesis and differentially predicting treatment responses will be major challenges.
“The treat-to-target recommendations provide a basis for implementation of a strategic, routine approach in clinical practice, but will need to re-evaluated for appropriateness and practicability in the light of new insights,” Aletaha said. – by Shawn M. Carter
Aletaha D, et al. Management of RA: Targets and options. Presented at: Congress of Clinical Rheumatology Annual Meeting; May 12-15, 2015; Destin, Fla.
Disclosure: Aletaha reports no relevant financial disclosures.