Adherence to a Treat-to-Target Strategy in Early Rheumatoid Arthritis: Results of the Dutch Rheumatoid Arthritis Monitoring Remission Induction Cohort

Background/Purpose: A treat-to-target (T2T) approach has proven to be more effective in reaching remission in early rheumatoid arthritis (RA) than usual care [1]. However, T2T has not been fully implemented in all rheumatology clinics. In 2006, six hospitals participating in the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry implemented a T2T strategy. In this DREAM remission induction cohort, early RA patients are treated according to a T2T strategy aiming at remission (Disease Activity Score in 28 joints (DAS28) < 2.6) [2]. The recommendations regarding T2T included regular assessment of the DAS28 and an advice regarding subsequent DAS28-driven treatment. The objective of this study was to evaluate the adherence to this T2T strategy.

Methods: A medical chart review was performed among a random sample of 100 RA patients of the DREAM remission induction cohort. At all scheduled visits, it was determined whether the clinical decisions were compliant to the T2T recommendations. Reasons for deviating from the recommendations were explored.

Results: The 100 patients contributed to a total of 1115 visits. The mean (standard deviation, SD) follow-up time was 28 (10) months and the mean (SD) number of visits was 11 (4) per patient. The DAS28 was available in 97.9% (1092/1115) of the visits, of which the DAS28 was assessed at a frequency of at least every three months in 88.3% (964/1092). Adherence to the treatment advice was observed in 69.3% (757/1092) of the visits. In case of non-adherence when remission was present (19.5%, 108/553), most frequently medication was tapered or discontinued when it should have been continued (7.2%, 40/553) or treatment was continued when it should have been tapered or discontinued (6.2%, 34/553) (Figure 1A). In case of non-adherence when remission was absent (42.1%, 227/539), most frequently medication was not intensified when an intensification step should have been taken (34.9%, 188/539) (Figure 1B). In almost half of these cases, low disease activity was observed (DAS28 ≤ 3.2). The main reason for non-adherence was discordance between disease activity status according to the rheumatologist and DAS28. Other frequently observed reasons were: side effects, patient wish and unknown.

Conclusion: The recommendations regarding T2T were successfully implemented and high adherence was observed. This demonstrates that the implementation of T2T is feasible in RA in daily clinical practice.

References: [1] Schipper et al. Ann Rheum Dis. 2012;71(6):845-50. [2] Vermeer et al. Arthritis Rheum. 2011;63(10):2865-72.