As treatment options for rheumatoid arthritis (RA) have changed — becoming more plentiful — so has the approach to treating the condition. In the past, before effective treatments were developed, treating RA was primarily about supportive measures, such as pain and symptom control. Now, the recommendation is to treat early and aggressively using the treat-to-target model to get the condition under control.
But do people with RA actually receive care in this way?
What is treat-to-target?
You may have heard of the treat-to-target approach. In cases of diabetes and high blood pressure, a medication is continually adjusted until the conditions are under control. If one medication is not effective, another medication will be prescribed. This will be repeated until blood sugar and blood pressure are normal. This method, now used to treat RA as well as diabetes and hypertension, is also called tight control.
By using this approach for RA, there is a greater chance of achieving control of the condition. That is, remission or low disease activity. This not only makes you feel better, but also protects your joints, your heart, and other systems in your body from being damaged by RA.
The reason behind aggressive treatment can be illustrated with the campfire analogy: “It’s much easier to put out a candle or campfire than it is to extinguish a roaring forest fire that’s out of control,” explained W. Benjamin Nowell, Ph.D., director of patient-centered research, CreakyJoints and an ArthritisPower co-principal investigator, in a telephone interview.
To “put out the fire,” the American College of Rheumatology (ACR) recommends treating both new and existing cases of RA using the treat-to-target approach. Further, treatment suggestions include disease modifying antirheumatic drugs (DMARDs) for milder cases of RA, with a preference for methotrexate, which is considered the “gold standard” of RA treatment. For moderate or severe cases, the suggestions are to use more than one DMARD or include biologics.
Barriers to treatment optimization
Unfortunately, this approach does not appear to be used in clinical practice as much as is recommended. Dr. Nowell recently presented a poster at EULAR 2018 showing the results of a study based on data from the Arthritis Power app. Of the individuals included in the study, about 70 percent experienced high disease activity, but only two thirds of these were offered a treatment change at the most recent appointment with their rheumatologist. As well, people tended to defer to the doctor’s treatment goals and judgment that no change was needed, rather than relying on their own assessment.
Dr. Nowell speculated that there is “still somewhat of a gap between the way that doctors think about treating a disease like RA and the way the patients think about it.” For instance, “the doctor might be thinking of it in a purely laboratory sense, in terms of lab readings; patients are thinking of it in terms of: ‘How much pain or fatigue am I feeling?’”
Individuals tracked their disease activity using the RAPID3 self-report measure and Nowell felt that this may not be the best tool.
“We need more research to find a good measure that both doctor and patient can agree on, so the tracking is more effectively understood on both sides,” he said.
Another possible factor affecting the low treatment optimization recommendations is the influence of the patient’s comfort level with taking medication. Also, other factors (besides RA) could be causing pain and fatigue, Dr. Nowell said.
How to optimize your RA treatment
Treatment optimization through using treat-to-target can be beneficial for anyone with RA, both those new to the condition and RA veterans. Getting the best control possible of RA will improve your overall health. You doctor is an important partner in this process, but you also bring valuable experience to the table.
Educating yourself about RA, how it affects your body, and what can be done to control the condition will enable you to have a different type of discussion with your doctor. This knowledge, combined with your experience of day-to-day living with RA, is an important part of discussing and agreeing upon treatment goals. Talk to your doctor about your feelings about medication so they can address them. And be aware of your limits, which might impact the effectiveness of your treatment. This will help you to get treatment tailored to your unique needs.