Treating rheumatoid arthritis to target: recommendations of an international task force

Josef S Smolen, Daniel Aletaha, Johannes W J Bijlsma, Ferdinand C Breedveld, Dimitrios Boumpas, Gerd Burmester, Bernard Combe, Maurizio Cutolo, Maarten de Wit, Maxime Dougados, Paul Emery, Alan Gibofsky, Juan Jesus Gomez-Reino, Boulos Haraoui, Joachim Kalden, Edward C Keystone, Tore K Kvien, Iain McInnes, Emilio Martin-Mola, Carlomaurizio Montecucco, Monika Schoels, Désirée van der Heijde, T2T Expert Committee, Jose Louis Andreu, Martin Bergman, Harald Burkhardt, Vivian Bykerk, Mario Cardiel, Filip Codruta, Hector Corominas, Alexandros Drosos, Patrick Durez, Hani ElGabalawy, Cristina Estrach, Bruno Fautrel, Gianfranco Ferracioli, Roy Fleischman, Joao Eurico Fonseca, Cem Gabay, Clara Gjesdal, Laure Gossec, Winfried Graninger, Espen Haavardsholm, Sesilie Halland, Pekka Hannonen, Jamie Henderson, Jonathan Kay, Wenche Koldingsnes, Marios Kouloumas, Ieda Maria Laurindo, Marjatta Leirisalo-Repo, Carlomaurizio Montecucco, Peter Nash, Mikkel Ostergaard, Andrew Ostor, Karel Pavelka, José Peirera da Silva, Kim Horslev Peterson, Duncan Porter, Enid Quest, Evangelos Romas, Marieke Scholte, Luigi Sinigaglia, Tuulikki Sokka, Ewa Stanislawska, Tsutomu Takeuchi, Guillermo Tate, Athanasios Tzioufas, Peter Villiger, Josef S Smolen, Daniel Aletaha, Johannes W J Bijlsma, Ferdinand C Breedveld, Dimitrios Boumpas, Gerd Burmester, Bernard Combe, Maurizio Cutolo, Maarten de Wit, Maxime Dougados, Paul Emery, Alan Gibofsky, Juan Jesus Gomez-Reino, Boulos Haraoui, Joachim Kalden, Edward C Keystone, Tore K Kvien, Iain McInnes, Emilio Martin-Mola, Carlomaurizio Montecucco, Monika Schoels, Désirée van der Heijde, T2T Expert Committee, Jose Louis Andreu, Martin Bergman, Harald Burkhardt, Vivian Bykerk, Mario Cardiel, Filip Codruta, Hector Corominas, Alexandros Drosos, Patrick Durez, Hani ElGabalawy, Cristina Estrach, Bruno Fautrel, Gianfranco Ferracioli, Roy Fleischman, Joao Eurico Fonseca, Cem Gabay, Clara Gjesdal, Laure Gossec, Winfried Graninger, Espen Haavardsholm, Sesilie Halland, Pekka Hannonen, Jamie Henderson, Jonathan Kay, Wenche Koldingsnes, Marios Kouloumas, Ieda Maria Laurindo, Marjatta Leirisalo-Repo, Carlomaurizio Montecucco, Peter Nash, Mikkel Ostergaard, Andrew Ostor, Karel Pavelka, José Peirera da Silva, Kim Horslev Peterson, Duncan Porter, Enid Quest, Evangelos Romas, Marieke Scholte, Luigi Sinigaglia, Tuulikki Sokka, Ewa Stanislawska, Tsutomu Takeuchi, Guillermo Tate, Athanasios Tzioufas, Peter Villiger

Abstract

Background: Aiming at therapeutic targets has reduced the risk of organ failure in many diseases such as diabetes or hypertension. Such targets have not been defined for rheumatoid arthritis (RA).

Objective: /st> To develop recommendations for achieving optimal therapeutic outcomes in RA.

Methods: A task force of rheumatologists and a patient developed a set of recommendations on the basis of evidence derived from a systematic literature review and expert opinion; these were subsequently discussed, amended and voted upon by >60 experts from various regions of the world in a Delphi-like procedure. Levels of evidence, strength of recommendations and levels of agreement were derived.

Results: The treat-to-target activity resulted in 10 recommendations. The treatment aim was defined as remission with low disease activity being an alternative goal in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with appropriate therapeutic adaptation to reach the desired state within 3 to a maximum of 6 months was recommended. Follow-up examinations ought to employ composite measures of disease activity which include joint counts. Additional items provide further details for particular aspects of the disease. Levels of agreement were very high for many of these recommendations (> or =9/10).

Conclusion: The 10 recommendations are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA based on evidence and expert opinion.

Conflict of interest statement

Competing interests This work was supported by an unrestricted educational grant from Abbott Immunology. Abbott affiliates were not involved in the programme or any voting. At the end of the voting process, the Expert Committee was asked to vote in an anonymous fashion if they felt they had been influenced by the sponsoring of the event by Abbott. This ballot resulted in an agreement of 8.7/10 that they did not consider that the fact that Abbott was sponsoring this programme created a bias. The handling editor was F Berenbaum.

Figures

Figure 1
Figure 1
Algorithm for treating rheumatoid arthritis (RA) to target based on the recommendations provided in box 1 and discussed in more detail in the explanatory notes. Indicated as separate threads are the main target (remission and sustained remission) and the alternative target (low disease activity in patients with long-term disease), but the approaches to attain the targets and sustain them are essentially identical. Adaptation of therapy should usually be done by performing control examinations with appropriate frequency and using composite disease activity measures which comprise joint counts.

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