Treat to Target: First identify the target!
Treat to target (T2T) is the new buzzword in rheumatology which has made us all practicing clinicians excited and optimistic about the outlook of the disease affecting our patients. We suddenly feel like armed soldiers who have identified the target to conquer and will now embark on the path to achieve it with our machinery of conventional synthetic DMARDs, new-age biologic warfare (read monoclonal antibodies) and the recently acquired drone missile ie. targeted synthetic DMARDs. This is a significant transition from the “Pyramid” approach 1 in the last century which painted such a depressing picture for the patients and physicians alike, resulting in the embossed belief of the inevitable crippling nature of this disease in patients and lack of their faith in conventional medicines. The growth of Rheumatology in the last three decades has definitely helped dismantle these convictions. However, the most important question to ask in a country like ours is “How do we define targets in our clinical setting”.
T2T concept gained momentum towards the end of the first decade of the 21st century after reports of success in Rheumatoid arthritis management using a regimented approach of frequent clinical assessments and medication adjustments including their dosages resulting in better disease outcomes and prevention of joint damage 2, 3. This was helped with the previous research into defining and validating the disease activity measures and correlating them with the long term functional outcomes 4. Several disease activity measures and their composite scores to define remission have been proposed 5. Interestingly, the target that initially identified complete remission as a desired goal was refined to include low disease activity as an expected outcome based upon the feedback of patients and consumers on the committees 6. Even more importantly, the disease outcome measures that need to be used in the Indian context have to be further simplified to tailor them to a resource limited setting 7.
Similar T2T approaches have now been published for SpA, Psoriatic arthritis and other peripheral spondyloarthritis and have been based upon rigorous work done in the recent past to develop and validate the outcome measures and prove their sensitivity to change after treatments 8. Similar aspirational targets have been proposed for SLE which in my view point require further validation 9. These have been developed as a tool which is not based upon the prior studies focussed on developing and validating them as clinically meaningful outcome measures. They are intended to be measured in prospective clinical cohorts including pharmaceutical trials to prove their usefulness in treating this unfortunate prototype systemic inflammatory disease which has largely missed out on bearing the fruits of the growth of monoclonal antibody treatments due to its disease heterogeneity.
Lastly, the most important piece of this puzzle is the patient choice. The target that we set for our patients need to be individualised based upon their clinical, social, economical and demographic characteristics keeping in mind the first principle of medicine ‘Primum non nocere”. The targets in our routine clinical settings are more likely going to be moving targets based upon lots of non-medical reasons rather than fixed upon a SDAI score of 3.3 or lower. Rheumatology is a speciality which requires clinical and social skill sets. Our targets cannot be something as simple as a systolic BP of <130mmHg or a HbA1C <7%.
Quote
Sir William Osler:
The good physician treats the disease; the great physician treats the patient who has the disease.
References:
Pravin Hissaria
Clinical Immunologist, Immunopathologist and Rheumatologist
Senior Staff Specialist
Royal Adelaide Hospital / SA Pathology
Adelaide SA 5000