Using a ‘treat-to-target’ approach aiming for clinical remission in rheumatoid arthritis

Bakker, 2007Escalas, 2012Nikiphorou, 2020Studenic, 2022Yokogawa, 2020

An individualised induction strategy (treatment plan) helps to define targets for therapy. A ‘treat-to-target’ approach, aiming for optimal management of disease activity and clinical remission, is considered best practice and recommended for all people with RA; see Induction and maintenance of clinical remission in rheumatoid arthritis.

If clinical remission is not achievable, an acceptable target is minimal or low disease activity. Regular monitoring of disease activity and adjustment of immunomodulatory therapy are required to achieve this.

Note: The goal of treatment for rheumatoid arthritis is to achieve clinical remission, but where this is not possible, low disease activity is an acceptable goal.

Disease-modifying antirheumatic drugs (DMARDs) are used to reduce or eradicate synovitis, improve pain and prevent joint damage in RA. Treatment choice can be complex and combination therapy may be required. Systemic corticosteroids are often combined with conventional synthetic DMARDs (csDMARDs) during the induction stage to provide rapid symptom relief (eg analgesia). Induction therapy with csDMARDs should be started as soon as possible.

Patients who have an inadequate response to csDMARDs may require treatment with a biological or targeted-synthetic DMARD (b/tsDMARD).

Clinical remission can be achieved in up to 40% of patients on immunomodulatory drugs. Most patients will require maintenance therapy indefinitely because RA rarely goes into drug-free remission. Even patients with well-controlled disease may have persistent symptoms and flares (ie increases in disease activity).

Decisions to change or escalate DMARD therapy should be a specialist decision, based on the likelihood of achieving or maintaining clinical remission. The decision to adjust DMARD therapy also depends on the patient’s comorbidities, drug preference and potential drug toxicity.

Some immunomodulatory drugs used in the treatment of RA have potentially adverse effects on reproductive health in both females and males. The choice of immunomodulatory drugs needs careful consideration in people of childbearing potential, including children and adolescents. See Immunomodulatory drug use and reproductive health for more details.