Ultimately, we must remember that it is important to distinguish active disease from established damage when treating to target, given that active disease can be modified but damage cannot. Also, treating to target may have differential efficacy when employed as a treatment strategy in patients with early stage versus late stage disease. Indeed, while aiming for remission in all patients may seemingly make sense, aiming for this target in patients with late- or very late–stage disease may not be feasible. In these patients, we may have to recognize that “formal” remission may not be possible and low disease activity may be the best we are able to achieve.
Despite the challenges and potential limitations of this approach to therapy, we respectfully propose that it is time to refine our concept of “treating to target” in the care of patients with RA.
Despite the challenges and potential limitations of this approach to therapy, we respectfully propose that it is time to refine our concept of “treating to target” in the care of patients with RA. This is best accomplished by adopting and integrating the overarching principles and recommendations of the International Task force in our clinical practices.
Dr. Bernstein is a fellow in the division of rheumatology at Hospital for Special Surgery, in New York, N.Y. Dr. Gibofsky is professor of medicine and public health at Weill Medical College of Cornell University and attending rheumatologist at Hospital for Special Surgery, both in New York, N.Y. He is chair of the United States “Treat to Target” Committee and a member of the International Group.
References
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- Grigor C, Capell H, Stirling A, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): A single-blind randomised controlled trial. Lancet. 2004;364:263-269.
- Verstappen SM, Jacobs JW, van der Veen MJ, et al. Intensive treatment with methotrexate in early rheumatoid arthritis: Aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial). Ann Rheum Dis. 2007;66:1443-1449.
- Goekoop-Ruiterman YPM, de Vries-Bouwstra JK, Allaart CF, et al. Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study). Arthritis Rheum. 2008;58:S126-S135.
- van Tuyl LH, Lems WF, Voskuyl AE. Tight control and intensified COBRA combination treatment in early rheumatoid arthritis: 90% remission in a pilot trial. Ann Rheum Dis. 2008;67:1574-1577.
