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Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force
  1. Josef S Smolen1,2,
  2. Ferdinand C Breedveld3,
  3. Gerd R Burmester4,
  4. Vivian Bykerk5,
  5. Maxime Dougados6,
  6. Paul Emery7,8,
  7. Tore K Kvien9,
  8. M Victoria Navarro-Compán3,
  9. Susan Oliver10,
  10. Monika Schoels2,
  11. Marieke Scholte-Voshaar11,
  12. Tanja Stamm1,
  13. Michaela Stoffer1,
  14. Tsutomu Takeuchi12,
  15. Daniel Aletaha1,
  16. Jose Louis Andreu13,
  17. Martin Aringer14,
  18. Martin Bergman15,
  19. Neil Betteridge11,
  20. Hans Bijlsma16,
  21. Harald Burkhardt17,
  22. Mario Cardiel18,
  23. Bernard Combe19,
  24. Patrick Durez20,
  25. Joao Eurico Fonseca21,22,
  26. Alan Gibofsky23,
  27. Juan J Gomez-Reino24,
  28. Winfried Graninger25,
  29. Pekka Hannonen26,
  30. Boulos Haraoui27,
  31. Marios Kouloumas11,
  32. Robert Landewe28,
  33. Emilio Martin-Mola29,
  34. Peter Nash30,
  35. Mikkel Ostergaard31,
  36. Andrew Östör32,
  37. Pam Richards11,
  38. Tuulikki Sokka-Isler33,
  39. Carter Thorne34,
  40. Athanasios G Tzioufas35,
  41. Ronald van Vollenhoven36,
  42. Martinus de Wit11,
  43. Desirée van der Heijde3,8
  1. 1Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  2. 22nd Department of Medicine, Hietzing Hospital, Vienna, Austria
  3. 3Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  4. 4Department of Rheumatology, Clinical Immunology Free University and Humboldt University, Charité-University Medicine, Berlin, Germany
  5. 5Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, USA
  6. 6Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
  7. 7Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
  8. 8NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  9. 9Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  10. 10Susan Oliver Associates, North Devon, UK
  11. 11EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
  12. 12Division of Rheumatology, Department of internal Medicine, Keio University School of Medicine, Tokyo, Japan
  13. 13Rheumatology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
  14. 14Department of Medicine III, University Medical Center TU Dresden, Dresden, Germany
  15. 15Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
  16. 16Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, and VU University Medical Center, Amsterdam, The Netherlands
  17. 17Division of Rheumatology, Department of Medicine, Johann-Wolfgang-Goethe University Frankfurt, German
  18. 18Centro de Investigación Clínica de Morelia, Morelia, Michoacán, Mexico
  19. 19Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
  20. 20Pôle de Recherche en Rhumatologie, Institut de Recherche Experimentale et Clinique, Université Catholique de Louvain and Cliniques Universitaires Saint-Luc, Brussels, Belgium
  21. 21Rheumatology Research Unit, Instituto de de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
  22. 22Rheumatology Department, Lisbon Academic Medical Centre, Lisbon, Portugal
  23. 23Weill Medical College, Cornell University Hospital for Special Surgery, New York, USA
  24. 24Rheumatology Unit, Santiago University Clinical Hospital, Santiago de Compostela, Spain
  25. 25Division of Rheumatology, Medical University of Graz, Graz, Austria
  26. 26Department of Medicine, Central Hospital, Jyväskylä, Finland
  27. 27Institut de Rhumatologie de Montréal, Quebec, Canada
  28. 28Academic Medical Center, University of Amsterdam, Amsterdam, and Atrium Medical Center, Heerlen, The Netherlands
  29. 29University Hospital La Paz, Madrid, Spain
  30. 30University of Queensland, Brisbane, Queensland, Australia
  31. 31Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
  32. 32Rheumatology Clinical Research Unit, School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK
  33. 33Department of Rheumatology, Central Hospital, Jyväskylä, Finland
  34. 34Division of Rheumatology, Southlake Regional Health Centre, Newarket, Ontario, Canada
  35. 35Department of Pathophysiology, School of Medicine, University of Athens, Greece
  36. 36Rheumatology Clinic, Karolinska University Hospital, Stockholm, Sweden
  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}, josef.smolen{at}


Background Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.

Objective To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.

Methods A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.

Results The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1–3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).

Conclusions The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.

  • Rheumatoid Arthritis
  • Outcomes research
  • Treatment
  • Early Rheumatoid Arthritis
  • Disease Activity

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  • Review
    Michaela A Stoffer Monika M Schoels Josef S Smolen Daniel Aletaha Ferdinand C Breedveld Gerd Burmester Vivian Bykerk Maxime Dougados Paul Emery Boulos Haraoui Juan Gomez-Reino Tore K Kvien Peter Nash Victoria Navarro-Compán Marieke Scholte-Voshaar Ronald van Vollenhoven Désirée van der Heijde Tanja A Stamm