The treat-to-target strategy is so straightforward it borders on common sense: A patient and her healthcare provider develop a target — either remission or minimal disease activity — and, with medication, they work toward that goal at a speedy pace. Progress is measured using a disease-activity scoring system. If a patient doesn’t improve by a three-month (or in some cases, one-month) benchmark, the treatment is intensified.
Treat-to-target is widely used by rheumatologists for patients with rheumatoid arthritis. (In a study published in 2015, rheumatoid arthritis patients who were treated to target were 52 percent more likely to achieve remission than their peers receiving traditional treatment.)
But with psoriatic arthritis, treat-to-target has been slower to catch on. The target, it seems, is a moving one.
“Heterogeneity of disease in psoriatic arthritis makes it more complex,” says Dr. Arthur Kavanaugh, a rheumatologist and clinical immunologist practicing at UC San Diego Health in California. “In addition to peripheral inflammatory arthritis, as patients with rheumatoid arthritis have, patients can have spinal inflammatory arthritis, skin psoriasis, nail psoriasis, enthesitis, and potentially concomitant irritable bowel disease and uveitis.”
Earlier this year, Annals of the Rheumatic Diseases published updated treat-to-target recommendations for psoriatic arthritis. According to the recommendations, the treatment target should be clinical remission, but low disease activity could be an alternative.
As Dr. Kavanaugh noted in his email interview with HealthCentreal, the report also highlights the complexity of measuring activity in a disease that manifests in both the joints and skin. Should rheumatologists use a scoring system to assess disease activity on the skin? Should dermatologists assess joint pain?
According to the report: “At some point, the discussion was stopped because all arguments had already been heard with no resolution of the methodological dissent. Given this difference of opinions, it was suggested that further research needed to be performed in [psoriatic arthritis].”
Dr. Kavanaugh, who serves on the board of the international Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, says there’s room for growth.
“I think we can do better,” he says. “There was a nice study from Norway published last year in the Journal of Rheumatology showing that even in a country with great healthcare access and great access to medications, that a number of people did not have great disease control. Psoriatic arthritis lags behind rheumatoid arthritis in that regard.”
The study of 141 patients with psoriatic arthritis, which Dr. Kavanaugh co-authored, found that only 22.9 percent of patients met the criteria for minimal disease activity. Roughly 30 percent of patients had never taken disease-modifying drugs at all.
“It takes a while for new concepts to be adopted,” Dr. Kavanaugh says. “Treat-to-target started earlier in rheumatoid arthritis and has become more accepted. It is newer to psoriatic arthritis, so hopefully it will get accepted more and more over time.”
Patient preferences matter as well, he says.
“Treat-to-target, being new in psoriatic arthritis, is something patients have not heard a lot about, again lagging behind rheumatoid arthritis,” says Dr. Kavanaugh. If treat-to-target is something you would consider, talk to your doctor about his or her knowledge of the strategy.
What’s especially important, Dr. Kavanaugh says, is the physician’s role in “evaluating all domains of disease and working with the patient to present treatment strategies to achieve the best outcome in all domains.”