At the Water's Edge

One of the topics that was prevalent at this year’s ACR Annual Scientific Meeting was the concept of Treating to Target. This approach to rheumatology care involves identifying treatment goals for patients with rheumatoid disease and modifying treatments when the goals are not reached. For instance, if a patient is started on methotrexate to treat rheumatoid arthritis, follow up evaluations should be done in a given timeframe (e.g. 1 month, 3 months) to see if the treatment is working. If it is not, the treatment will be modified by perhaps increasing the dose or adding a biologic drug. The patient would continue to be monitored with disease activity measured on a regular basis, and additional treatment modifications given if the disease is still not under control. There are multiple methods of measuring disease activity -- which is a whole other topic of conversation -- but the ACR has identified 6 disease activity measures that they recommend for use in a clinical setting in conjunction with a treat to target strategy: CDAI, DAS28 [ESR or CRP], PAS, PAS-II, RAPID-3, and SDAI -- Click here to view full recommendations from ACR. The doctor will use the assessment criteria to determine whether the treatment has allowed the patient to achieve the goal of low disease activity or remission.

To me, “Treat to Target” seemed like the new buzz word in rheumatology, and I heard this topic mentioned in the Exhibit Hall, saw posters in the Poster Hall and I even attended a whole session on the topic on the last day of the meeting. To be honest, I was a little bit annoyed at first. I mean, really, isn’t this just common sense? If the treatment doesn’t work, try something else. It doesn’t seem like something that needs to be researched or discussed at length. Or does it? I know rheumatology patients who have been put on treatments and have been forced to stay on them for years, even though the treatment brought no relief of symptoms. Perhaps that’s the irony of common sense: it’s not all that common.

"Despite the push from various stakeholders in the health care system to standardized disease activity assessment in RA and growing evidence that treating to target is effective, most US rheumatologists do not routinely use standardized measures in clinical practice. The myriad available instruments and lack of formal recommendations on which measures are best suited for different practice settings likely contribute to this lack of implementation." -- Rheumatoid Arthritis Disease Activity Measures: ACR Recommendations for Use in Clinical Practice

The session that I went to (Rheumatoid Arthritis – Treating to Target: How to Incorporate Rheumatoid Arthritis Disease Activity Measures into Routine Practice) was actually very well done. Among all of the sessions that I attended, I would say that this was the most engaging, with great speakers and presentations, and with important, practical knowledge being shared. It was also the only session I attended that used videos and humor, which may or may not be beside the point. One of the things that caught my attention here was a discussion of what the goal, or the “target”, of treat to target should be. That seems obvious, too. In lieu of a cure, the best we can hope for now is remission – or, rather, sustained remission. But remission is not always the goal in a treat to target strategy. What?? Why not? Here’s a quote I wrote down from the session:

“The goal should be low disease activity – other factors may influence whether or not to have solely remission as the goal.”

As I thought about that, it began to make more sense. Although I didn’t previously know the term for, it my rheumatologist practices Treating to a Target. I thought back to a year ago when I was having a flare in symptoms and was so apprehensive about getting my blood work done, knowing that my elevated ESR would prompt my doctor to recommend changes in treatment. I thought about my hesitancy to try a new and different drug, without knowing if it would even work as well as my current therapy. Even my doctor told me that when selecting a different treatment to try, it’s a roll of the dice – we don’t have a way right now to know which treatments will work best for which patients. And it is a gamble, because I do have something to lose. If a new treatment does not work as well as my current one, it could have some serious consequences for my daily life.
I did end up switching drugs last year – from Enbrel to Humira – and my doctor closely monitored me to determine how well the new treatment was working – at 1, 2 and 3 month intervals. What was the result of treatment modification for me? I was able to get back to a state of low disease activity. It’s not remission, but it’s close. I can function close to normal each day with very minimal pain or stiffness -- and I have no side effects from my treatment. Would I risk that to try another treatment just so I could have a chance to get to the ultimate goal of sustained remission? No. If I were to experience another sustained period of flaring symptoms, would I consider changing drugs again? Yes. So there we have it – treating to target for me does mean treating with the goal of low disease activity. Common sense though it may be, treating to target is an important strategy that should be adopted by all rheumatologists, even though the “target” goals and disease activity measures may differ slightly based on the practice or on the patient. The take away message I got from the session is this: “If you measure it, it will improve.”