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Optimisation of a treat-to-target approach in rheumatoid arthritis: strategies for the 3-month time point
  1. Daniel Aletaha1,
  2. Farideh Alasti1,
  3. Josef S Smolen1,2
  1. 1Division of Rheumatology, Medical University Vienna, Vienna, Austria
  2. 2Second Department of Medicine, Hietzing Hospital, Vienna, Austria
  1. Correspondence to Professor Daniel Aletaha, Division of Rheumatology, Department of Internal Medicine 3, Medical University Vienna, Vienna 1090, Austria; daniel.aletaha{at}meduniwien.ac.at

Abstract

Background Treat-to-target (T2T) is a widely accepted management strategy for rheumatoid arthritis (RA) with a key decision point at 3 months after treatment initiation. At this time point, it remains unclear which patients will benefit from treatment adaptation or from continuation of existing treatment.

Methods We performed a pooled analysis of patient-level clinical trial data of patients with RA. We used a diagnostic testing methodology and a probabilistic approach employing logistic regression to investigate which levels of response at 3 months can inform treatment decisions in regard to achieving the target at 6 months.

Results To be at least 80% sensitive for achieving the low disease activity (LDA) target at 6 months, a change at 3 months in Simplified Disease Activity Index/Clinical Disease Activity Index (SDAI or CDAI) of 58% needs to be observed at 3 months. Higher changes are needed to sensitively predict remission (REM). Not reaching the (minor) SDAI 50% response level is afflicted with very low negative likelihood ratios (LRs) (0.28 for LDA and 0.07 for REM at 6 months). Experiencing (major) SDAI 85% response has substantial positive LRs of 9.2 for reaching LDA and 6.2 for reaching REM at 6 months. In logistic regression, the change at 3 months is significantly associated with reaching of the target at 6 months.

Conclusions The 3-month time point is a critical decision point. Not achieving minor responses at 3 months makes reaching of the treatment target at 6 months highly unlikely, while reaching major responses is highly predictive of reaching the treatment target.

  • Rheumatoid Arthritis
  • Disease Activity
  • Treatment

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