What is the best way to treat rheumatoid arthritis? While no one treatment works best for everyone, most people with RA can benefit from a clear strategy for making treatment-related decisions. In fact, when it comes to controlling RA inflammation, choosing and sticking to a treatment strategy may be more important than picking a medication. 1 Drosos AA, Pelechas E, Voulgari PV. Treatment strategies are more important than drugs in the management of rheumatoid arthritis. Clin Rheumatol. 2020;39(4):1363-1368. doi:10.1007/s10067-020-05001-x
The treat-to-target strategy—sometimes referred to as T2T—has been shown to improve overall treatment results and is recommended by the American College of Rheumatology.
The 4 components of the treat-to-target strategy for RA
Experts recommend using the treat-to-target approach to manage rheumatoid arthritis as well as many other chronic conditions, such as heart disease and diabetes. It involves 4 essential components that, when combined, may lead to low RA disease activity or RA remission, which means few to no symptoms and less long-term joint damage.
The 4 essential components of a treat-to-target approach include:
1. Setting a target
Rheumatoid arthritis inflammation is typically measured using lab tests, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and joint swelling identified during a physical examination (or using imaging techniques, such as ultrasound of the joints). In treat-to-target, doctors and patients aim to lower RA inflammation until a specific lab test benchmark is met. For example, a newly diagnosed person whose CRP level is 57 mg/L may have a goal to get to a CRP of less than 5 mg/L; or someone with 15 swollen and 13 tender joints may have a goal of 2 or fewer swollen and tender joints.
2. Regular testing
The treat-to-target approach recommends regular testing and patient evaluation by the healthcare provider to monitor progress towards the target. Lab tests may be ordered as often as every month and in-office visits may be done every 2 months, but there is no prescribed schedule. The patient and doctor will decide together how often testing or clinic visits will take place and commit to that schedule (see #4).
Once the benchmark goal has been reached and symptoms are well-managed, the testing or patient evaluation may be done less frequently.
3. Changing treatment as needed
If lab test results and patient evaluation don’t show a pattern of acceptable progress, then the RA treatment plan is promptly changed. A physician may recommend increasing the RA medication dosage, adding a new RA medication, or switching medication to a different RA medication.
While changing a treatment plan typically involves making changes to the medication regimen, it may also involve one or more lifestyle changes, such as quitting smoking, making dietary changes, exercising regularly, improving sleep, treating depression and/or anxiety, and meditating daily. Research suggests these types of lifestyle changes can reduce rheumatoid arthritis inflammation.
4. Sharing decision-making as a team
Using the treat-to-target strategy, the physician and patient make decisions together. The patient’s priorities and the physician’s medical expertise help inform choices about testing, reasonable goals, and changes in treatment.
Treat-to-target may be effective because it requires frequent testing and patient evaluation that encourages doctors and patients to be more aggressive in changing a treatment plan that isn’t working. It’s also helpful to have a specific, remission-based goal. The treat-to-target approach can result in sustained remission for those with early RA and can also be effective for those with longstanding RA.
Research suggests that very few physicians and patients use all 4 elements of the treat-to-target model. 2 Yu Z, Lu B, Agosti J, et al. Implementation of Treat-to-Target for Rheumatoid Arthritis in the US: Analysis of Baseline Data From a Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2018;70(5):801-806. doi:10.1002/acr.23343 Physicians report a few reasons for not using a treat-to-target approach, including a lack of time and appointment availability as well as the belief that patients don’t want to take more medication or switch medications.
It’s also important to keep in mind that lab tests can be influenced by factors other than rheumatoid arthritis. For example, a person’s CRP level may increase because of an infection or weight gain (obesity is linked to low-level inflammation).
Talking to your doctor
Despite the possible challenges, most patients who have rheumatoid arthritis say they are interested in trying the treat-to-target strategy. 2 Yu Z, Lu B, Agosti J, et al. Implementation of Treat-to-Target for Rheumatoid Arthritis in the US: Analysis of Baseline Data From a Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2018;70(5):801-806. doi:10.1002/acr.23343 If you would like to use the treat-to-target model, talk to your physician.
There’s no question that rheumatoid arthritis can be a challenge to manage. But thanks to advances in RA treatment, the options for those with RA are steadily improving.
- 1 Drosos AA, Pelechas E, Voulgari PV. Treatment strategies are more important than drugs in the management of rheumatoid arthritis. Clin Rheumatol. 2020;39(4):1363-1368. doi:10.1007/s10067-020-05001-x
- 2 Yu Z, Lu B, Agosti J, et al. Implementation of Treat-to-Target for Rheumatoid Arthritis in the US: Analysis of Baseline Data From a Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2018;70(5):801-806. doi:10.1002/acr.23343