The 2017 updated treat-to-target recommendations for spondyloarthritis
| LoE | GoR | Voting | LoA (0–10) Mean (SD) | ||
| Overarching principles | |||||
| A. | The treatment target must be based on a shared decision between patient and rheumatologist | n.a. | n.a. | 69.4% | 9.7 (0.7) |
| B. | Treatment to target by measuring disease activity, and adjusting therapy accordingly, improves outcomes | n.a. | n.a. | 83.3% | 9.3 (1.2) |
| C. | SpA and PsA are multifaceted systemic diseases; the management of musculoskeletal and extra-articular manifestations should be coordinated, as needed, between the rheumatologist and other specialists (such as dermatologist, gastroenterologist, ophthalmologist) | n.a. | n.a. | 86.1% | 9.8 (0.5) |
| D. | The goals of treating the patient with SpA or PsA are to optimise long-term health-related quality of life and social participation through control of signs and symptoms, prevention of structural damage, normalisation or preservation of function, avoidance of toxicities and minimisation of comorbidities | n.a. | n.a. | 86.1% | 9.9 (0.3) |
| E. | Abrogation of inflammation is important to achieve these goals | n.a. | n.a. | 94.4% | 9.2 (1.8) |
| Recommendations | |||||
| 1. | The treatment target should be clinical remission/inactive disease of musculoskeletal (arthritis, dactylitis, enthesitis, axial disease) and extra-articular manifestations | 5 | D | 75% | 9.2 (1.8) |
| 2. | The treatment target should be individualised based on the current clinical manifestations of the disease; the treatment modality should be considered when defining the time required to reach the target | 5 | D | 94.4% | 9.6 (0.8) |
| 3. | Clinical remission/inactive disease is defined as the absence of clinical and laboratory evidence of significant disease activity | 2c | B | 88.9% | 9.6 (0.6) |
| 4. | Low/minimal disease activity may be an alternative treatment target | 2b/5* | B/D* | 97.2% | 9.6 (0.9) |
| 5. | Disease activity should be measured on the basis of clinical signs and symptoms, and acute phase reactants | 2c | B | 88.9% | 9.3 (0.9) |
| 6. | Validated measures of musculoskeletal disease activity and assessment of cutaneous and/or other relevant extra-articular manifestations, should be used in clinical practice to define the target and to guide treatment decisions; the frequency of the measurements depends on the level of disease activity | 5 | D | 84.4% | 9.4 (0.8) |
| 7. | In axial SpA, ASDAS is a preferred measure and in PsA DAPSA or MDA should be considered to define the target | 2c | B | 51.6% | 7.9 (2.5) |
| 8. | The choice of the target and of the disease activity measure should take comorbidities, patient factors and drug-related risks into account | 5 | D | 91.4% | 9.5 (1.7) |
| 9. | In addition to clinical and laboratory measures, imaging results may be considered in clinical management | 5 | D | 93.9% | 9.1 (1.3) |
| 10. | Once the target is achieved, it should ideally be maintained throughout the course of the disease | 2c | B | 100% | 9.8 (0.5) |
| 11. | The patient should be appropriately informed and involved in the discussions about the treatment target, and the risks and benefits of the strategy planned to reach this target | 5 | D | 76.5% | 9.9 (0.4) |
*2b (A) for PsA, 5 (D) for axial SpA.
ASDAS, Ankylosing Spondylitis Disease Activity Score; DAPSA, Disease Activity index for PSoriatic Arthritis; LoA, level of agreement among the task force members (mean (SD); LoE, level of evidence and GoR, grade of recommendation, both according to the Oxford Centre of Evidence-Based Medicine (evidence as provided by clinical trials underlying the recommendation); MDA, Minimal Disease Activity; n.a., not applicable; PsA, psoriatic arthritis; SpA, spondyloarthritis.