by Nathan Wei
Posted on Monday 12th of September 2011
Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic, autoimmune disease that affects more than 2 million Americans. Patients with RA can develop debility and limited functional ability as a result of persistent pain, swelling, and stiffness.
In addition, mounting evidence indicates that chronic systemic inflammation is a primary cause of accelerated cardiovascular events such as heart attacks and strokes. This is one reason for the increased mortality associated with RA.
Fortunately, newer therapies have allowed the idea of complete remission of this disease to be an achievable target.
The Europeans have created a set of standards called “Treat to Target.” These were elegantly summarized by Dr. Paul Emery, Professor of Rheumatology, University of Leeds, United Kingdom.
I’ve summarized the principles below:
1.RA treatment must be based on a shared decision between the patient and the rheumatologist.
2.The primary goal is to maximize quality of life through control of symptoms, prevention of joint damage, normalization of function, and participation in social activities.
3.Stopping inflammation is key.
4.Measuring disease activity and adjusting therapy optimizes outcomes.
5.The primary goal should be complete remission.
6.Remission is defined as the absence of signs and symptoms of inflammation.
7.While remission is the goal, a low amount of disease activity may be acceptable, especially in long-standing disease.
8.Until the treatment target is reached, drug therapy should be adjusted at least every 3 months.
9.Measure of disease activity should be documented regularly at least monthly in [patients with severe disease and less frequently in patients with a low amount of disease activity.
10.Validated measuring devices should be used.
11.Disease activity as well as functional impairment and joint damage all factor into decision making.
12.The desired treatment target should be maintained throughout.
13.The choice of target value might be influenced by patient factors such as other associated illnesses as well as drug-related risks.
14.The patient needs to be informed about the treatment target as well as the treatment strategy to be employed.
Now, these “principles” may sound like common sense but they are well thought out and probably should be adopted here in the States. Most of us who treat rheumatoid arthritis a lot already use a form of this Treat to Target approach.
These principles are grounded in data collected during multiple clinical trials of biologic therapies in RA. So they have been tested and validated already on many occasions.
The key point to understand is this. Remission is the goal. It is not only desirable and possible, it is a must. While the European Treat to Target approach focuses on the joint disease, the unspoken message is this… RA is a systemic condition. The tighter the control of disease, the less likelihood of potential cardiovascular events.
Also, there is some early evidence that the incidence of lymphoma, which is increased in RA, may be reduced with tighter control.
When I first started practice, it was not uncommon to see patients in wheelchairs. Now, it is a rarity... and should never happen with newly diagnosed disease.
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