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Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force
  1. Josef S Smolen1,2,
  2. Jürgen Braun3,
  3. Maxime Dougados4,
  4. Paul Emery5,
  5. Oliver FitzGerald6,
  6. Philip Helliwell5,
  7. Arthur Kavanaugh7,
  8. Tore K Kvien8,
  9. Robert Landewé9,10,
  10. Thomas Luger11,
  11. Philip Mease12,
  12. Ignazio Olivieri13,
  13. John Reveille14,
  14. Christopher Ritchlin15,
  15. Martin Rudwaleit16,
  16. Monika Schoels2,
  17. Joachim Sieper17,
  18. Martinus de Wit18,
  19. Xenofon Baraliakos3,
  20. Neil Betteridge18,
  21. Ruben Burgos-Vargas19,
  22. Eduardo Collantes-Estevez20,
  23. Atul Deodhar21,
  24. Dirk Elewaut22,
  25. Laure Gossec23,
  26. Merryn Jongkees18,
  27. Mara Maccarone18,
  28. Kurt Redlich1,
  29. Filip van den Bosch22,
  30. James Cheng-Chung Wei24,
  31. Kevin Winthrop25,
  32. Désirée van der Heijde26
  1. 1Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  2. 22nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
  3. 3Rheumazentrum Ruhrgebiet, Herne, Germany
  4. 4Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
  5. 5Division of Rheumatic and Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
  6. 6Department of Rheumatology, St. Vincents University Hospital, Dublin, UK
  7. 7Division of Rheumatology, Allergy, Immunology, University of California, San Diego, California, USA
  8. 8Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  9. 9Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  10. 10Atrium Medical Center, Heerlen, The Netherlands
  11. 11Clinic and Polyclinic of Dermatology, University of Münster, Münster, Germany
  12. 12Swedish Medical Center and University of Washington, Seattle, Washington, USA
  13. 13Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
  14. 14Division of Rheumatology, University of Texas Health Science Center at Houston, Houston, Texas, USA
  15. 15Allergy, Immunology and Rheumatology Division, The Center for Musculoskeletal Medicine, University of Rochester Medical Center, Rochester, New York, USA
  16. 16Endokrinologikum Berlin, Berlin, Germany
  17. 17Medical Department I, Rheumatology, Charité Campus Benjamin Franklin, Berlin, Germany
  18. 18EULAR standing committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
  19. 19Rheumatology Department, Faculty of Medicine, Hospital General de México Universidad Nacional Autónoma de México, Mexico City, Mexico
  20. 20Department of Rheumatology, Reina Sofia University Hospital of Córdoba/IMBIC, Córdoba, Spain
  21. 21Division of Arthritis and Rheumatic Diseases, Oregon Health & Sciences University, Portland, USA
  22. 22Laboratory for Molecular Immunology and Inflammation, Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
  23. 23Department of Rheumatology, Pitié Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France
  24. 24Division of Allergy, Immunology and Rheumatology, Institute of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
  25. 25Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
  26. 26Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Professor Josef S Smolen, Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria; josef.smolen{at}meduniwien.ac.at; josef.smolen{at}wienkav.at

Abstract

Background Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).

Objective To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.

Methods Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.

Results Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9–10 (10: maximum agreement) for all recommendations. A research agenda was formulated.

Conclusions The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.

Keywords
  • Treat-to-target
  • spondyloarthritis
  • ankylosing spondylitis
  • psoriatic arthritis
  • therapy

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

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