Background/Purpose: Presently the goals of rheumatoid arthritis (RA) therapy are to control symptoms, to prevent joint damage and disability.  Attaining long-term clinical remission or at least low disease activity (LDA) is mandatory to reach these goals. Treat-to-target (T2T) protocols have been shown to be feasible and superior to non-protocolled care in treating early RA patients in daily clinical practice. However, not all patients may equally benefit from these treatment protocols. Not reaching remission or loss of remission results in periods of moderate to high disease activity in which signs and symptoms impair the health status of patients. Moreover, longer periods of moderate to high disease activity probably affect long term outcome. The objective of the present study was to identify the proportion of RA patients not receiving optimal long-term clinical benefit from T2T therapy.

Methods: Data were used from patients with early RA included in the DREAM remission induction cohort between January 2006 till June 2010. Patients were treated according to a step-up strategy aiming at remission, which consisted of methotrexate, followed by the addition of sulfasalazine and subsequently exchange of sulfasalazine with a TNFi in case of persistent disease activity. Patients were evaluated at the outpatient clinic at baseline and every 3 months thereafter. ESR-DAS28 was used to assess if patients were in LDA (DAS28 ≤3.2) or remission (DAS28 <2.6) at every visit. T2T therapy is considered not fully effective in case the patient’s disease activity is moderate to high over a period of ≥ 6 months. 

Results: Five-year follow-up data were available from 229 patients (63.3% female, mean age 57.7 years). Between 1 and 5 years after disease onset and start of T2T treatment, the mean DAS28 scores over time remained stable and below the cutoff for remission (Figure). In this period however, 67 (29.3%) patients experienced at least one episode of ≥ 6 months with low, moderate or high disease activity (DAS28> 2,6). Moreover, 34 (14.8%) patients experienced at least one episode of ≥ 6 months with moderate or high disease activity (DAS28> 3,2).

Conclusion: At the population level, T2T therapy in early RA results in stable low disease activity. However, even in this very well managed population, a relevant proportion of patients is not always in remission.  This suggests an unmet need that deserves additional study to further improve RA management.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/treat-to-target-of-remission-is-effective-but-not-all-patients-are-always-in-remission/