Arthritis Treatment: Treat to Target For Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis affecting more than two million Americans.

It is a systemic, chronic, autoimmune disease for which there is no cure. RA is capable of causing severe damage not only to joints but to other organ systems as well including the lungs, heart, peripheral nervous system, bone marrow, and eyes.

The 2010 criteria formulated by the American College of Rheumatology as well as the European League Against Rheumatism developed new standards to improve the early diagnosis of the disease. This would, of course, lead to earlier implementation of treatment.

The criteria specifies that a classification of "definite RA" is based on clinical confirmation of inflammation of at least one joint; absence of an alternative explanation that better explains the inflamed joint, and achievement of a total score of 6 or more (out of 10) from individual scores in four areas: number and site of involved joints, positive blood tests for rheumatoid factor and anti-CCP, elevated blood tests for inflammation, and symptom duration.

As a result of these more clearly defined criteria, there has been the move towards "treating to target" meaning treatment should be aimed at a patient with goal of achieving either remission or low disease activity (LDA) as quickly as possible.

There are three steps to this approach:

• The first is to define the target as remission.
• The second is to assess the patient every three months (at a minimum) to see if remission has been achieved.
• The third is to change therapy if remission is not achieved by the three month mark.

Remission is defined as having no more than one swollen or tender joint, a C-reactive protein (CRP) less than or equal to 1 mg/dl, and a patient global assessment of less than or equal to one on a one to ten scale.
Some investigators choose to use a more elaborate Simplified Disease Activity Index which requires, in my estimation, more calculation.

Since disease activity has been shown to correlate strongly with disease presence at one year, after start of treatment, it is extremely important to monitor disease activity frequently. Because of this evidence it's critical to consider a change in treatment early if the patient is not responding and to monitor changes closely.

While not every patient will achieve remission, they should at least be in the LDA category. These changes, I believe are an improvement on the "gestalt" approach we've used for many years to evaluate patients.