Treat-to-Target Strategy Significantly Improves HRQoL in RA, Other Rheumatic Diseases

A treat-to-target (T2T) strategy was shown to significantly improve both clinical outcomes and health-related quality of life (HRQoL) among patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), and gout, according to a study published in Seminars in Arthritis and Rheumatism.¹ T2T was particularly successful in lowering disease activity and achieving treatment targets.

As most of the eligible studies identified in the review focused on RA, investigators point to a lack of T2T trials in other rheumatic diseases. However, the limited studies available have shown clinical and functional benefits from this method in active PsA and SpA as well as an improvement in clinical and radiological outcomes in gout.

The T2T strategy for rheumatic diseases was originally created by an international task force in 2010, with a concentration on RA. The recommendations, based on a combination of expert opinion and randomized clinical trials, centered on targeting remission or low-disease activity by adjusting therapy as needed during routine office visits. This approach as remained a primary goal of RA management.²

“In this study, we comprehensively reviewed the literature on T2T strategies in rheumatic diseases to determine what lessons could be learned from previous trials to guide development of T2T trials in systemic lupus erythematosus (SLE) and other connective tissue diseases,” wrote a team of investigators led by Yanjie Hao, PhD, consultant rheumatologist at Peking University First Hospital, Beijing, China, and associated with the University of Melbourne at St Vincent's Hospital.

A systematic review and meta-analysis of the safety and efficacy of a T2T approach in adults with rheumatic diseases was conducted by searching PUBMED, CINAHL, and EMBASE databases for relevant clinical trials or observational studies between January 1990 and December 2023. Data on clinical, physical, and radiologic outcomes, adverse events, and cost-effectiveness were collected. A random-effect meta-analysis was performed for the most common outcomes among the eligible RA studies.

Of the 7896 studies identified, 66 ultimately fit inclusion criteria, of which 50 focused on RA, 12 on gout, 3 on PsA, and 1 on SpA.

Among the RA studies, most (83.3%, n = 20/24) showed significantly better clinical outcomes in patients managed with a T2T strategy compared with usual care. Additionally, results of the meta-analysis revealed these patients were more likely to achieve Disease Activity Score-28 (DAS-28) response at 1-year (pooled standardized mean difference [SMD]: 0.47 [0.26–0.69], P <.001) and were more likely to be in remission (pooled relative risk [RR]: 1.68 [1.47–1.92], P <.001). Further, a T2T approach with a predefined treatment protocol was more clinically effective than without a protocol.

More than half of the studies (57.9%, n = 11/19) that evaluated HRQoL and physical function demonstrated a T2T strategy significantly increased the likelihood of improvement. The meta-analysis for the mean change of the Health Assessment Questionnaire (HAQ) confirmed these findings (pooled SMD: 1.48 [0.46–2.51, P = 0.004). Similarly, 55.6% (n = 5/9) showed greater benefits regarding radiographic progression. Adverse events were not shown to occur more often with this treatment approach and—of the 2 studies that assessed cost—a T2T strategy was shown to be more cost-effective than usual care.

Among the SpA and PsA studies, the T2T approach was shown to be more effective than usual care in both clinical and functional benefits. However, this did not extend to radiologic outcomes. In the 12 gout studies, T2T more effectively controlled a patients’ serum uric acid (sUA) level. Additionally, 2 of the studies showed a T2T approach could prevent erosion development and crystal deposition.

Investigators noted limitations including the significant heterogeneity among the studies, such as differing reported outcomes, definitions of outcomes and treatment targets, and follow-up duration. Additionally, the impact of the individual medications used in the T2T strategies were not assessed. Drug choice also varied widely throughout the 30-year period evaluated. For example. although conventional DMARDs were more popular during the early T2T studies, biologics were becoming increasingly more utilized in recent years. Lastly, there were a limited number of trials studying PsA and SpA and the follow-up durations for these were relatively short.

“This SLR highlighted that T2T strategy studies in other rheumatic diseases such as SLE are needed,” investigators concluded. “More studies with longer follow-up would be ideal to confirm the conclusion from these studies.”

References

1. ^{Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum. Published online May 21, 2024. doi:10.1016/j.semarthrit.2024.152465}
2. ^{J.S. Smolen, R. Landewé, F.C. Breedveld, M. Dougados, P. Emery, C. Gaujoux-Viala, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis, 69 (6) (2010), pp. 964-975}