Sunday September 2, 2012
Treating to target
By Drs YEAP SWAN SIM, GUN SUK CHYN and HESELYNN HUSSEIN
Aiming at a treatment target for rheumatoid arthritis leads to better outcomes compared to traditional follow-up care.
IF you have high blood pressure (BP) or diabetes, you should be aware of what the doctor would like to achieve with treatment.
In people with high blood pressure, the aim of treatment would be to reduce the BP to below 140/90, ie the target is to get the BP below 140/90.
If there are additional medical problems such as diabetes, heart disease or previous heart attacks, then the target would be to lower the BP even further, to below 130/80.
In diabetes, the aim is for the blood sugar to be as normal as possible. Thus, the target is for the fasting blood sugar to be below 5.5 mmol/l, or for the glycosylated haemoglobin (HbA1c) – the measure of diabetic control over the previous three months – to be below 7.0%.
The doctor would discuss these “numbers” with you before treatment is started, and regular measurements are done to ensure that these targets are achieved during treatment. Achieving these targets leads to improved outcomes, with a reduction in organ damage/complications.
Rheumatoid arthritis (RA) is chronic (ie long-term) arthritis leading to joint pain and swelling due to inflammation. Inflammation is the process in RA by which the joints get painful and swollen.
Untreated RA leads to joint damage, and consequently, physical disability, with the attendant reduced quality of life.
The need for early treatment in RA has been highlighted in many previous articles. Early treatment with disease-modifying anti-rheumatic drugs (DMARDs) has been shown to reduce joint damage, with ensuing better physical function.
Apart from early treatment, once patients are onmedication, tight (or good) control of their RA would lead to a better outcome.
However, in the past, there has been no consensus on such targets for RA patients.
In 2008, an international Steering Group of rheumatologists (doctors treating arthritis) and patients met to develop a set of recommendations for the tight control of RA – “treat to target” (T2T).
This was based on an extensive review of the research evidence available, followed by discussion amongst the international panel of over 60 doctors and some patients to achieve consensus.
It was felt to be a timely initiative for several reasons. Firstly, there are now various methods commonly available to measure the amount of RA activity more reliably (rather like the HbA1c for diabetic patients) so that decisions on treatment changes can be made based on recognised and accepted activity scores.
Secondly, medications have become available that can more effectively control RA compared to previously available drugs.
Thirdly, research studies have shown that aiming at a treatment target for RA leads to better outcomes compared to traditional follow-up care.
The resulting recommendations were then disseminated to rheumatologists worldwide. Overall, there was very good support from the rheumatologists, including those surveyed in Malaysia, with the recommendations.
The next step was completed earlier this year when the patient version of the recommendations was published. This was based on discussions with a few of the doctors involved in the initial T2T recommendations and nine RA patients from various parts of Europe.
The patient recommendations and its main concepts are discussed further below. It is hoped that if patients are aware of the recommendations for the treatment of RA, they can start to understand why treatment is important, and have a dialogue with their rheumatologist about the treatment aims for their disease and how it can be achieved.
The over-riding principle of T2T is that there is discussion between the doctor and patient about their treatment of RA and the goal of their treatment. Ideally, there should be agreement on the goal to maximise long-term quality of life by controlling the disease to stop joint inflammation.
There is no doubt that uncontrolled inflammation in RA leads to joint damage. So it is important that RA disease activity/inflammation is measured regularly, and the treatment adjusted if the target is not achieved.
This is an important concept – patients with RA are typically on several types of medication, and there can be a reluctance on their part to adjust medication, especially if they are already feeling better and can cope with the few swollen joints that are still present.
In addition, some RA patients are concerned that the potential benefits do not outweigh the potential harm of the treatment, which makes adjustment of, and compliance with, treatment difficult.
The recommendations that follow explain what the aim of treatment should be, and how to get there.
The best target for patients with RA would be to get to a state of clinical remission. This means that there are no swollen or tender joints, and the markers of inflammation in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), are within normal limits.
If remission is not possible, then a state of “low disease activity” may be an acceptable alternative. In this state, there may be still some signs of inflammation, such as one or two swollen joints, or a slightly raised ESR or CRP.
Both remission and low disease activity states significantly reduce the chances of progressive joint damage in RA, in contrast to patients with moderate to high disease activity. It is suggested that patients with moderate or high disease activity be seen in clinics more frequently, so that treatment can be adjusted until the RA goes into remission. Once under control, the frequency of the visits can be reduced.
However, the recommendations do recognise that the process should be individualised; recommendation 9 states that, “Selecting the appropriate measurement of disease activity and target may be influenced by the individual situation: the presence of other diseases, patient-related factors or drug-related safety risks”.
Of course, these recommendations suggest what should happen in the ideal situation, where both doctor and patient have enough time and resources to achieve the optimum outcomes in RA.
Nevertheless, as in the other medical conditions where doctors are encouraged to treat to a target, doctors treating RA should behave no differently in treating to a target.
Even if resources are limited, there is no reason why we should not be trying to aim for the ideal and achieve as much as possible.
Therefore, to all the patients with RA reading this, talk to your doctor about T2T!
Overreaching T2T principles
·Decisions regarding the treatment of RA must be made by the patient and rheumatologist together.
·The most important goal of treatment is to maximise long-term health-related quality of life. This can be achieved through:
(i) Control of disease symptoms like pain, inflammation, stiffness and fatigue.
(ii) Prevention of damage to joints and bones.
(iii) Regaining normal function and participation in daily activities.
·The most important way to achieve these goals is to stop joint inflammation.
·Treatment toward a clear target of disease activity gives the best results in RA. This can be achieved by measuring disease activity and adjusting therapy if the target is not achieved.
1. The primary target of treatment of RA should be clinical remission.
2. Clinical remission means that significant signs and symptoms of the disease that are caused by inflammation are absent.
3. Although remission should be the target, it is not possible for some patients, in particular, those with long disease duration. Therefore, low disease activity may be an acceptable alternative.
4. Until the desired treatment target is reached, drug therapy should be adjusted at least every three months.
5. Disease activity must be measured and documented regularly. For patients with high or moderate disease activity, this must be done every month.
For patients in a sustained low disease activity state or remission, this can be done less frequently (eg every three to six months).
6. Combined disease activity measurements, which include joint examinations, are needed in routine clinical practice to guide treatment decisions.
7. Besides disease activity, treatment decisions in clinical practice should also consider damage to the joints and restrictions in activities of daily living.
8. The desired treatment target should be maintained throughout the remaining course of the disease.
9. Selecting the appropriate measurement of disease activity and target may be influenced by the individual situation: presence of other diseases, patient-related factors or drug-related safety risks.
10. The patient has to be appropriately informed about the treatment target and the strategy planned to reach this target under the supervision of the rheumatologist.
1. Smolen JS, Aletaha D, Bijlsma JWJ et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010; 69: 631-7. doi:10.1136/ard.2009.123919.
2. De Wit MPT, Smolen JS, Gossec L, van der Heijde DMFM. Treating rheumatoid arthritis to target: the patient version of the international recommendations. Ann Rheum Dis 2011; 70: 891-5. doi:10.1136/ard.2010.146662.
■ Dr Yeap Swan Sim, Dr Gun Suk Chyn and Dr Heselynn Hussein are part of the Malaysian T2T Steering Committee. This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail email@example.com. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.