Going into Remission from RA



The Facts About Treat-to-Target Therapy for RA

Should you live with your RA or try to put it into remission? Treat-to-target rheumatologists believe that aggressive RA treatment has its merits.

By Dennis Thompson Jr., HealthDay News

Medically Reviewed by Niya Jones, MD, MPH

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One reason treat-to-target therapy hasn't caught on in the US: there's a lack of rheumatologists.
One reason treat-to-target therapy hasn't caught on in the US: there's a lack of rheumatologists.

Imagine doctors taking the tack that all rheumatoid arthritis should be put into remission, with patients nearly or completely free of pain and symptoms. Physicians would treat each person aggressively, swapping medications and therapies every few months until they hit on the therapy that brings RA under control.

This concept already exists. Called "treat-to-target," it's already been used to help with chronic medical conditions like diabetes, high blood pressure, and high cholesterol. Rheumatologists in Europe and the United States now are using it with RA patients.

"Previously, we have looked to improve symptoms in patients by 25 percent or 50 percent," said Christopher Morris, MD, a rheumatologist in Kingsport, Tenn., and a spokesperson for the American College of Rheumatology. "Those of us in practice have maintained that may be fine and dandy for academic studies, but we feel our goal is to get 100 percent improvement."

With treat-to-target, doctor and patient agree on a goal — complete RA remission, Dr. Morris said. The doctor assigns a treatment, and then uses a combination of measures to see how the patient is progressing. These measures can include:

  • A patient's self-assessment of how they feel
  • The doctor's assessment of the patient's symptoms, using standardized questionnaires
  • Laboratory tests like measures of inflammatory proteins in the blood that show to what extent RA is being affected by treatment

One More RA Treatment Choice

The benefit of treat-to-target is that by bringing rheumatoid arthritis under control quickly, patients can avoid the joint damage that RA can cause over time. They'll feel better and be less likely to become disabled, explained Robert Landewé, MD, a professor of rheumatology at the University of Amsterdam and a practicing rheumatologist at Atrium Medical Centre in Heerlen, The Netherlands. Patients can maintain their jobs and experience better physical functioning.

RELATED: 3 Things Arthritis Patients Wish Their Docs Would Do

Research published in Arthritis Care and Research in August 2013 showed that after three years of treat-to-target therapy, about 70 percent of patients in a Dutch clinical trial achieved sustained remission from RA, mostly through the use of conventional RA drugs. A review of a number of clinical trials over the past decade published in April 2014 in Arthritis and Rheumatology found that treat-to-target can achieve better outcomes than standard care.

About 83% of urban areas in the United States have no rheumatologist.

There are some drawbacks, however, that have slowed its adoption as a primary strategy for treating rheumatoid arthritis:

  • There's no agreement on doctors' measurements.Doctors continue to debate which measures will best reflect how a patient is responding to a particular treatment. For example, a January 2014 report in Arthritis Care and Research found that ultrasound tests greatly improved the evaluation of a patient's RA relative to a standard score card typically used called the Disease Activity Score.
  • Patients often aren't the best judge of their own progress.A patient may report themselves feeling fine even if their disease hasn't improved. The time of day they see the rheumatologist can affect how they feel — people with RA tend to feel better in the early afternoon than the morning, for example. They might report feeling worse if they are nearing the end of the cycle of a biologic drug that's given every eight weeks. Even mood can alter a person's perception. "If they're in a good mood, they sometimes feel a lot better than when they are in a bad mood," Morris said.
  • Aggressive treatment can be hard on patients.It's estimated that between 35 and 60 percent of RA patients aren't taking basic rheumatologic medications. A treat-to-target strategy would require them to take large doses of medications that could come with serious side effects, including increased risk of infection, heart failure, and liver disease. "You need to take more intensive drugs, so there is potentially more toxicity," Dr. Landewé said. If patients don't stick to their treatment and take their drugs as directed, they could throw off the whole program.

One major impediment for the adoption of treat-to-target in the United States is that the strategy requires frequent visits to the rheumatologist so progress can be tracked and treatment changed if necessary. About 83 percent of urban areas in the United States with a population between 10,000 and 50,000 have no rheumatologist, with the nearest specialist being an average 159 miles away.

"In Europe, there are more rheumatologists," Landewé said. "Patients live closer to their rheumatologist." European doctors also may be more inclined to try inventive therapies for patients, he added.

The Future of RA Treatment

Despite this, recommendations on treat-to-target from European and American rheumatology societies are generally similar, mainly differing in guidelines surrounding particular types of medications. "The Europeans and the Americans agree on the basic philosophy of treat-to-target," Landewé said.

If you want to try treat-to-target, just ask your rheumatologist, Morris said. "I think all of us in rheumatology want to get our patients under good control. It is being used increasingly in the U.S. because we're trying to come up with the best way to treat each patient.






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Date: 03.12.2018, 20:19 / Views: 44372