T2T Strategies Research Articles

Active implementation of low disease activity state as a treatment endpoint in childhood-onset systemic lupus erythematosus in routine practice is both feasible and associated with better outcomes

IntroductionTreat-to-target (T2T) strategies aim to facilitate tight disease control to improve outcomes. No previous studies evaluated prospectively the feasibility and impact of the T2T strategy in routine practice in childhood-onset SLE (cSLE).MethodsAdolescents and young adults (AYA) with cSLE were recruited for T2T implementation from a large tertiary centre over a period of 6 months and followed up at least twice over a prospective period of 12 months.ResultsDuring Oct 2022–April 2023, 135/162 (83.3%) AYA with cSLE had disease scores evaluated at their routine appointment to enable inclusion in the study, and 122/135 (91.2%) had their disease assessed, and a suitable treatment target agreed and documented at each routine clinical appointment over the 12 months prospective follow-up. T2T strategy led to improved disease control at 12 months: more AYA with cSLE achieved clinical remission off steroids (4.1% vs. 10.7%, P = 0.048), or minimum childhood-lupus low disease activity (cLLDAS) (81.9% vs. 91.8%, P = 0.022). Achieving minimum cLLDAS for longer than 3 months was associated with reduced damage accrual (HR = 1.7; 95%CI = 1.1–2.5; P < 0.0001) at 12 months.ConclusionT2T strategy implementation was achievable and associated with improved cSLE control. Spending at least 3/12 months in cLLDAS led to less damage accumulation.Key Points• This is the first large prospective study in AYA with cSLE to evaluate the impact of active T2T implementation in routine practice.• T2T strategies were feasible to implement in 122/135 (91.2%) AYA with cSLE in routine practice.• The T2T approach was associated with improved disease control and decreased damage accrual at 12 months.

Challenges in implementing treat-to-target in rheumatoid arthritis: a perspective from Brazilian rheumatologists

BackgroundPatient management in rheumatoid arthritis (RA) has evolved to a “treat-to-target” (T2T) approach, which entails intensive treatment and regular follow-up with the goal of achieving low levels of disease activity or clinical remission. Even though a T2T approach is endorsed by professional organizations and yields superior outcomes, its implementation remains incomplete. EVEREST (EleVatE care in RhEumatoid arthritiS with Treat-to-target) is a quality-improvement initiative designed to improve the widespread implementation of a personalized T2T strategy and enable patients with RA to reach their full potential for remission. We describe the Brazilian results from the Global T2T Survey, first part of the EVEREST program.MethodsBetween June and September 2022, we conducted an online survey targeting rheumatologists in Brazil. Our objective was to evaluate the barriers and knowledge gaps hindering the effective implementation of T2T strategies. To achieve this, we employed a set of multiple-choice questions specifically crafted to elicit responses categorized in a structured order.Results166 rheumatologists participated in the survey, 51% of them with more than 21 years of experience in rheumatology. Regarding the perceived challenges in the management of RA in clinical practice, the highest percentage of agreement/strong agreement among the participants was related to the contradictory results of disease activity measures (60%). In terms of the main barriers to assess the disease activity in clinical practice, the lack of adherence to treatment and contradictory assessments between patient-reported outcomes and composite measures were indicated by 75% and 59% of the participants, respectively, as a moderate/serious barrier. The most frequently knowledge and skill gaps related to the management of RA pointed out by the participants were on the difficulty to assess patients’ health literacy (54% stated to have no more than intermediate knowledge on standardized methods to assess it and 43% no more than intermediate skills on determining the level of health literacy of the patients). In general, the use of tools to support the management of RA patients in clinical practice was indicated to be unusual by the participants. Self-reflection questionnaires, patient education materials and treatment consideration checklists were pointed out as the least frequently used tools (85%, 64% and 62% of the participants stated to use them never, rarely, or only sometimes, respectively).ConclusionsOur findings indicate a greater need for design, selection, and uptake of practical strategies to further improve communication between healthcare providers and patients with RA, as well as for promoting well-informed, collaborative decision-making in their care.

Refining Treat-to-Target (T2T) strategies in Cryopyrin-Associated Periodic Syndromes (CAPS): The role of inflammatory markers.

Cryopyrin-Associated Periodic Syndromes (CAPS) encompasses a spectrum of Interleukin-1 (IL-1) driven systemic diseases with dramatic individual and societal burden. The study aimed to identify parameters and instruments to refine real-life Treat-to-Target (T2T) strategies and control CAPS disease activity. A single-centre, longitudinal study of consecutive children and adults diagnosed with CAPS and treated with anti-IL-1 therapy was performed. Demographics, clinical phenotype and NLRP3 gene variants in addition to serial inflammatory markers and Physician and Patient/Parent Global Assessments (PGA/PPGA) were captured. Effectiveness of anti-IL-1 T2T strategies and factors associated with therapy escalation were determined. A total of 54 CAPS patients with 759 follow-up visits were included; 31/54 (57%) were children; the median follow-up was 108 months (12-620). The moderate CAPS phenotype was present in 89%; overall 59% had pathogenic/likely pathogenic NLRP3 variants. Therapy adjustments were documented in 50/759 visits including 35 therapy escalations and 15 reductions; 74% of the therapy escalation visits were for children. At time of visit, 63% showed moderate, 37% severe clinical disease activity. Inflammatory markers remained largely normal. Significant improvement was observed in both PGA/PPGA throughout the study (p< 0.01). At the last follow-up, 96% of patients achieved remission. Guidance for refining real-life T2T strategies in CAPS cohorts can be drawn from serial assessments of PGA and PPGA reliably reflecting changes in disease activity. Individual parameters including age and NLRP3 gene variants are important predictors, while the sensitivity of inflammatory markers is limited due to the confounding anti-IL-1 therapy.

Evolving Concepts in Treat-to-Target Strategies for Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is characterised by a wide range of symptoms and a risk for irreversible organ damage, leading to increased morbidity and mortality. To improve long-term outcomes, innovative therapeutic goals have been explored, including attainment and maintenance of remission or low disease activity, with minimal use of glucocorticoids. Other goals encompass early diagnosis, potent yet less toxic therapies, appropriate glucocorticoid tapering, and better quality of life for the patients. Implementing a treat-to-target (T2T) approach involves treatment adjustments to achieve predefined objectives. Evidence from other chronic diseases, like hypertension and diabetes, supports the success of target-based approaches. In rheumatic diseases, the multitude of clinical features adds complexity to T2T strategies, but in rheumatoid arthritis, T2T has yielded improved outcomes. The application of T2T in SLE requires realistic therapeutic goals and practical tools for their measurement. International task forces have developed T2T recommendations for SLE, focusing on limiting disease activity, preventing organ damage, and minimising glucocorticoid use, while considering patients' quality of life. Advancements in defining clinically meaningful remission and low disease activity states, coupled with promising novel therapies, have spurred progress in the management of SLE.

P045 Google Internet Searches Related to Inflammatory Arthritis: an Observational Study Using Google Trends Data

Abstract Background/Aims Inflammatory arthritis (IA) care involves a paradox. Rheumatologists focus on reducing disease activity through treat-to-target (T2T). But surveys/qualitative studies show patients’ main concern is pain. As these studies include a minority of patients, their findings may not be generalisable. The internet has transformed how patients access health information. Examining search engine data provides an alternative method to understand the health areas of most importance to people with IA. We examined publicly available Google search engine data, to determine the relative popularity of searches for different aspects of health made in conjunction with IA. Methods We used Google Trends data from 2011-2022 to determine the relative popularity of searches for “patient symptom” (pain; work; stiffness; fatigue; mood) and “T2T” (DMARDs; inflammation; synovitis; corticosteroids) domains made with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) in the UK/USA. Google Trends normalises a sample of search data by popularity over time and region, presenting it on a 0-100 scale at each time-point (100 represents the time-point with most searches). It allows comparisons of up to five search term combinations. We evaluated &amp;gt;100 search term combinations to ascertain the most popular “patient symptom” and “T2T” domains (comparing mean normalised scores across time-points). Results Patient Symptom Domains: in all IA forms in the UK/USA, pain was the most popular term. Its popularity increased over time. UK searches for pain gave mean scores of 58, 34, and 39 with RA, PsA, and AS. UK searches for other patient symptom domains gave mean scores ranging 2-7 with RA; no scores were generated with PsA/AS. In the USA, pain gave mean scores of 79, 51, and 63 with RA, PsA, and AS, compared to scores ranging 2-6 for other domains. T2T Domains: methotrexate was the most popular search term with RA and PsA in the UK (mean 28 and 21) and USA (mean 63 and 33); it was only slightly more popular than searches for synovitis and inflammation. For AS, in the UK and USA inflammation was most popular (mean 9 and 34). Most Popular Patient Symptom vs Most Popular T2T Domain: for RA, PsA, and AS, pain was substantially more popular in the UK (mean 58, 30, 52) and USA (mean 79, 54, 63) than methotrexate in RA and PsA in the UK (mean 16 and 14) and USA (mean 15 and 11) and inflammation in AS in the UK (mean 6) and USA (mean 8). Conclusion Pain is the most popular search term used with IA in Google searches in the UK/USA, supporting surveys/qualitative studies showing pain is the health aspect of most importance to people with IA. Routine pain assessments should be embedded within T2T strategies to ensure patient perspectives are considered. Disclosure M. Akthar: Grants/research support; ‘M.A. previously received funding by the National Institute for Health and Care Research (NIHR Academic Clinical Fellowship in Rheumatology)., The views expressed are those of the author and not necessarily those of the NIHR, NHS or the Department of Health and Social Care.’. K.J. Mason: Grants/research support; ‘K.J.M. is funded by the National Institute for Health and Care Research (NIHR; Grant Reference Number NIHR203281)., The views expressed are those of the author and not necessarily those of the NIHR, NHS, or the Department of Health and Social Care.’. I.C. Scott: Grants/research support; ‘I.C.S. is funded by the National Institute for Health and Care Research (NIHR Advanced Research Fellowship, NIHR300826)., The views expressed are those of the author and not necessarily those of the NIHR, NHS, or the Department of Health and Social Care.’

Evidence on treat to target strategies in polymyalgia rheumatica and giant cell arteritis: a systematic literature review.

To inform an international task force about current evidence on Treat to Target (T2T) strategies in PMR and GCA. A systematic literature research (SLR) was conducted in Medline, EMBASE, Cochrane Library, clinicaltrials.gov from their inception date to May 2022, and in the EULAR/ACR abstract database (2019-2021). Randomised clinical trials (RCTs) and non-randomised interventional studies published in English and answering at least one of the eleven PICO questions on T2T strategies, treatment targets and outcomes, framed by the taskforce, were identified. Study selection process, data extraction and risk of bias assessment were conducted independently by two investigators. Of 7809 screened abstracts, 397 were selected for detailed review and 76 manuscripts were finally included (31 RCTs, eight subgroup/exploratory analyses of RCTs and 37 non-randomised interventional studies). No study comparing a T2T strategy against standard of care was identified. In PMR RCTs, the most frequently applied outcomes concerned treatment (90.9% of RCTs), particularly the cumulative glucocorticoids (GC) dose and GC tapering, followed by clinical, laboratory and safety outcomes (63.3% each). Conversely, the most commonly reported outcomes in RCTs in GCA were prevention of relapses (72.2%), remission as well as treatment-related and safety outcomes (67.0% each). This SLR provides evidence and highlights the knowledge gaps on T2T strategies in PMR and GCA, informing the task force developing T2T recommendations for these diseases.

P653 Tight control and Treat to target increase the rates of Transmural remission and Transmural response in Crohn’s disease

Abstract Background increasing evidence support the use of Transmural remission as a treatment target in Crohn’s disease (CD) but few patients can reach it with currently available therapies. Treat-To-Target (T2T) and Tight-Control (TC) strategies may potentially improve these results. Methods Methods: single-center retrospective study including 123 CD patients with active colonoscopy (CN) and magnetic resonance enterography (MRE) at baseline and with available follow-up CN and MRE for reassessment of remission. We evaluated the effects of T2T and TC strategies on the rates of Transmural remission and Transmural response. Patient submitted to bowel surgery between examinations were excluded. Definitions CN activity: ulcers in non-operated patients or Rutgeerts score&amp;gt; i1 in operated patients; MRE activity: bowel thickness &amp;gt;3 mm and enhancement on T1/T2 sequences. Transmural remission: inactive CN and MRE at reassessment; Transmural response: improvement from baseline in either examination. T2T: treatment decisions resulting in both clinical remission (Harvey-Bradshaw &amp;lt;5) and fecal calprotectin remission (Fc &amp;lt;250 ug/g) at reassessment. TC: treatment decisions resulting in persistent Fc remission (≥ 2 consecutive results, including reassessment). Results 48.0% and 42.3% of patients followed a T2T and TC strategy, respectively. Transmural remission and Transmural response were reached by 33.3% and 69.1% of patients, respectively. T2T resulted in higher rates of Transmural remission (55.9% vs 12.5%, P&amp;lt;0.001) and Transmural response (91.5% vs 48.4%, P&amp;lt;0.001). TC was also associated with higher rates of Transmural remission (51.9% vs 19.7%, P&amp;lt;0.001) and Transmural response (90.4% vs 53.5%, P&amp;lt;0.001). In multivariate regression, T2T (OR 9.30 95%CI 2.85-30.30, P&amp;lt;0.001), TC (OR 3.85 95%CI 1.18-12.54, P=0.025) and starting biologic treatment (OR 3.63 95%CI 1.36-9.70, P=0.010) were independent predictors of reaching Transmural response. T2T was the only independent predictor of reaching Transmural remission (OR 6.540 95%CI 2.41-17.74, P&amp;lt;0.001). Conclusion Patients following a T2T and TC strategy presented higher rates of Transmural remission and Transmural response.

Management of moderate-to-severe plaque psoriasis with biologics: A treat-to-target position paper.

Treat-to-target (T2T) recommendations for the use of systemic therapies (including biologics) in patients with moderate-to-severe plaque psoriasis have been published by a few groups of experts worldwide. However, there remains considerable variability in the choice of target severity measure and timing of milestones. To develop consensus recommendations for implementing T2T strategies for the management of moderate-to-severe plaque psoriasis using biologics. An expert group of Canadian dermatologists (the Committee) convened to develop a T2T consensus statement. They held a virtual meeting during which a preliminary set of criteria was created. These criteria were then reviewed, modified, and recirculated until unanimous agreement was achieved. The Committee agreed that defining treatment target is multidimensional and should reflect objective severity measures, as well as clinician and patient-reported outcomes. The Committee unanimously proposes a criterion-based system for determining the achievement of treatment target. The proposed T2T approach presented here provides a clinical framework for defining treatment success, measuring progress toward treatment success, recognizing when treatment modifications are warranted, and recommending treatment optimization strategies.

Impact of Treat-to-Target Therapy on Bone Mineral Density Loss in Patients With Rheumatoid Arthritis: A Prospective Cohort Study.

BackgroundOsteoporosis is a common comorbidity of rheumatoid arthritis (RA). Although RA disease activity has been demonstrated to be associated with bone loss in previous studies, most of them were cross-sectional studies and not in the context of treat-to-target (T2T) strategies.ObjectivesThis study aimed to evaluate the association of disease activity with bone mineral density (BMD) changes in the context of T2T strategies in a prospective RA cohort.MethodsRA patients were enrolled from a prospective CENTRA cohort of Peking University First Hospital. The follow-ups have been scheduled every 3 to 6 months. BMD was repeated at baseline, 1 year, and then every other year. Demographics, baseline clinical features, laboratory data, and medications at each visit were recorded. Time-adjusted mean disease activity scores were adopted to reflect the overall disease activity during follow-up. The influence of univariable associations between predictors and BMD was investigated using linear regression.ResultsA total of 268 patients were included in our analysis. Their mean age was 50 (12.9) years, and 224 (83.6%) were women. The median (IQR) disease duration was 48.7 (107.6) months. Osteoporosis in the lumbar spine was observed in 23.1% of patients and 9.3% in the femoral neck at enrollment. Older age, higher SDAI score, and lower BMI were associated with osteoporosis at baseline. The proportion of patients who achieved DAS28-ESR, CDAI, and SDAI remission or LDA at the end of the first year was 71.5%, 68.8%, and 67.4%, respectively. Reevaluations of BMD at 1 year were applied to 144 patients. Mean decreases of BMDs were 1.75% at the lumbar spine and 1.40% at the femoral neck at 1 year from baseline, respectively. Patients who achieved remission had less yearly bone loss in the lumbar spine (p = 0.036). Female gender was identified as a risk factor in the multiple linear regression analyses, and lower disease activity and bisphosphonates were protective factors of continuous bone loss.ConclusionDisease activity is associated with bone loss in RA patients in the context of T2T strategies, and those who achieved remission had less yearly bone loss.

A treat-to-target approach is needed for Behçet's syndrome.

Treat-to-target (T2T) approach has improved outcomes in chronic diseases. The aim of this review is to discuss the long-term goals and review the evidence for possible targets that would predict the achievement of these goals for developing a T2T strategy for Behçet's syndrome. There are no trials comparing a tight control strategy to standard care in Behçet's syndrome but recent studies suggest better outcomes with earlier use of biologic agents compared with sustained conventional treatment. Fluorescein angiography may be a reliable tool for assessing remission in uveitis as fluorescein angiography findings were shown to predict relapses and long-term visual outcome. Good recanalization on Doppler ultrasonography can be a target for venous involvement as this was the only predictor of relapse. Fecal calprotectin levels were associated with small intestinal and colonic ulcers and may be used as a surrogate for remission of gastrointestinal involvement. There are several new treatment modalities that are tried for Behçet's syndrome and ongoing work on outcome measures for reliable disease assessment. In order to ensure the wise and efficient use of treatment modalities, development and implementation of T2T strategies are needed through multidisciplinary and multinational efforts that include patient research partners.

Treat to Target in Spondyloarthritis: Myth or Reality?

A treat-to-target (T2T) strategy is a treatment plan in which the clinician treats the patient aggressively enough to reach and maintain explicitly specified and sequentially measured goals. To apply a T2T strategy, some conditions should be met. First, a proactive, clear endpoint should be used and a threshold should be defined. Second, a choice between several effective therapies must be available. Third, the endpoint should be supported by findings from randomised controlled trials supporting early aggressive treatment. Fourth, the strategy should be cost-effective. Finally, it needs to be acceptable by the stakeholders. The objective of this review was to verify if the conditions for applying the T2T strategy were met in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), using a narrative review. Based on the currently available literature, the conditions for applying the T2T in PsA and axSpA were partially met. First, proactive outcome measures are available; however, there is no clear consensus regarding the optimal one. Second, there is a reasonable choice of approved therapies for both diseases. Third, additional randomised controlled trials demonstrating the effectiveness of a T2T approach are still needed. Fourth, cost-effectiveness studies are needed and should include patients from different healthcare systems. Fifth, the implementation of T2T recommendations in routine care and the adherence to its application in clinical practice should be promoted. In summary, preliminary data suggest that T2T might be beneficial to patients with PsA and axSpA. However, further studies are needed to meet all the criteria before strongly advocating for T2T strategies.

OP35 Effect of maintenance ustekinumab on corticosteroid-free endoscopic and clinical outcomes in patients with Crohn’s Disease - Week 48 analysis of the STARDUST trial

Abstract Background The STARDUST study demonstrated that ustekinumab (UST), using either a treat-to-target (T2T) or standard of care (SoC) strategy, may induce and maintain endoscopic and clinical response and remission in Crohn’s disease (CD). Primary endpoint, safety, and efficacy have been reported previously.1 Because corticosteroid (CS) sparing is an important aim of CD management, we compared the efficacy of UST T2T vs SoC in achieving CS-free clinical remission and endoscopic response. Methods Adult patients (pts) with moderate–severely active CD who were CDAI 70 responders after 16 weeks (W) of induction, comprising a single dose of UST 6 mg/kg iv followed by UST 90 mg SC at W8, were randomized to either T2T or SoC arms. In the T2T arm, choice of UST maintenance dosage (q12w or q8w) was based on endoscopic improvement at W16, followed by clinical and biomarker-directed dose escalation up to q4w; in the SoC arm, UST q12w or q8w dosage was based on EU SmPC. Primary endpoint was endoscopic response (Simple Endoscopic Score in CD [SES-CD] decrease from baseline [BL] ≥50%) at W48. For pts on CS at W16, CS tapering was mandatory. At W48, CS-free clinical remission (CDAI &amp;lt;150 and no CS for ≥30 days) and CS-free endoscopic response (reduction from BL in SES-CD ≥50% and no CS for ≥30 days) were evaluated. Results Of 500 pts enrolled, 441 achieved a CDAI 70 response at W16 and were randomized to T2T (n=220) or SoC (n=221); 79.1% and 87.3%, respectively, completed W48. Among clinical remitters and responders at W16 (start of CS tapering), in both T2T and SoC arms more than 70% were still in remission or response at W48 (Figure 1). CS use throughout 48 weeks of treatment is summarized in Table 1. At W48, in T2T and SoC arms similar rates were noted for CS-free endoscopic response (33.6% and 28.5%, respectively) and CS-free clinical remission (56.4% and 63.3%, respectively). Notably, in T2T and SoC arms the CS-free clinical remission rate among pts on CS at BL was 44.1% and 45.1%, respectively (Figure 2). Among W48 endoscopic responders (T2T, n=83; SoC, n=66), CS-free endoscopic response rate was 89.2% and 95.5%, respectively; among W48 clinical remitters (T2T, n=135; SoC, n=154), CS-free clinical remission rate was 91.9% and 90.9%, in T2T and SoC arms, respectively. Conclusion Pts treated with UST under T2T or SoC strategies achieved similar rates of CS-free clinical remission and endoscopic response over 48 weeks. Overall for pts on CS at BL, UST reduced the need for CS while achieving response/remission. Most (&amp;gt;89%) pts with endoscopic response/clinical remission at W48 were also CS-free responders/remitters. Reference

Treatment strategies are more important than drugs in the management of rheumatoid arthritis.

The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.

The role of ultrasound and magnetic resonance imaging for treat to target in rheumatoid arthritis and psoriatic arthritis.

The treat-to-target (T2T) approach has revolutionized the way we treat patients with rheumatic and musculoskeletal diseases. Recent attention has focused on imaging techniques, in particular musculoskeletal ultrasound and MRI as a focus for T2T strategies. Recently, a number of randomized clinical trials have been performed that compared tight clinical control vs control augmented by imaging techniques. While the three published trials have concluded that imaging does not add to tight clinical care, implementing imaging into the T2T strategy has actual advantages, such as the detection of subclinical involvement, and information on joint involvement/pathology and may possess potential advantages as evidenced by certain secondary endpoints. This review examines the findings of these studies and discusses the advantages and disadvantages of incorporating imaging into the T2T strategy.

Comorbidities-Their role in the treat to target concept for rheumatoid arthritis

Treat to target (T2T) strategies and comorbidities are closely related. Strong evidence exists for reducing the risk and extent of comorbidities, such as cardiovascular (CV) diseases, depression and infections by implementing T2T concepts and inducing good disease control of rheumatoid arthritis (RA) in this way. On the other hand existing comorbidities may hinder implementation of T2T concepts by aggravating RA or influencing rheumatologists to overcautiously use DMARD treatment. Among along list of potentially relevant comorbidities with RA, in this review two particularly relevant accompanying diseases with respect to T2T, CV diseases and infections, are selected for discussion in detail. The CV comorbidities are the main cause of death for RA patients and are triggered by RA-associated inflammatory mechanisms. Their negative influence on implementation of T2T strategies can be stopped or at least reduced by optimal control of RA activity with the help of selecting drugs with cardioprotective properties (such as biologicals, methotrexate and hydroxychloroquine) as well as assessing and treating traditional CV risk factors. Infections are among most important adverse events of DMARD treatment and can disturb the optimal use of these drugs and so hinder the success of the T2T strategy. Optimal infection prophylaxis and identification of high risk patients are particularly important and minimization of glucocorticoid use is critical to reduce the risk of infections. In summary, comorbidities are important potential risk factors for the success of T2T strategies.

Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry.

BackgroundTreat to target (T2T) is widely accepted as the standard of care for patients with rheumatoid arthritis (RA) and has been shown to be more effective than traditional routine care. The objective of this study was to compare the effectiveness of two T2T strategies in patients with early RA: a step-up approach starting with methotrexate (MTX) monotherapy (cohort I) versus an initial disease-modifying antirheumatic drug combination approach (cohort II).MethodsA total of 128 patients from cohort II were case–control-matched with 128 patients from cohort I on gender, age, and baseline disease activity. Twelve-month follow-up data were available for 121 patients in both cohorts. The primary outcome was the proportion of patients having reached at least one 28-joint Disease Activity Score (DAS28) score <2.6 (remission) during 12 months of follow-up. Secondary outcomes were time until remission was achieved and mean DAS28 scores at 6- and 12-month follow-up.ResultsAfter 12 months of follow-up, remission was reached at least once in 77.3 % of the patients in cohort II versus 71.9 % in cohort I (P = 0.31). Median time until first remission was 17 weeks in cohort II versus 27 weeks in cohort I (P = 0.04). A significant time by strategy interaction was found in mean DAS28 scores. Post hoc analysis revealed a significant difference in mean DAS28 scores between both cohorts at 6 months (P = 0.04), but not at 12 months (P = 0.36).ConclusionsThe initial combination strategy resulted in a comparable remission rate after 1 year but a significantly shorter time until remission. At 6 months, mean DAS28 scores were lower in patients with initial combination treatment than in those with step-up therapy. At 12 months, no significant differences remained in mean DAS28 scores or the proportion of patients in remission.

SAT0255 Clinical and Radiographic Outcomes at 2 Years and the Effect of TOCILIZUMAB Discontinuation following Sustained Remission in the Second and Third Year of the ACT-RAY Study

BackgroundIn ACT-RAY, MTX-IR patients (pts) with moderate to severe RA were randomized to either an add-on (tocilizumab [TCZ]+MTX) or a switch (TCZ+placebo [PBO]) strategy. Data at 24 and 52 weeks...

SP0066 What is the Target in Ra? Pursuing the Optimal Clinical Target

The concept of “Treat to Target” (T2T) has become embedded in the modern management of rheumatoid arthritis. Tight control of disease activity in the early stages of disease has been...

OP0042 Clinical and Radiographic Outcomes at Two Years and the Effect of Tocilizumab (TCZ) Discontinuation Following Sustained Remission in the Second Year of the Act-Ray Study

BackgroundIn ACT-RAY, MTX-IR patients (pts) with moderate to severe RA were randomized to either the add-on (TCZ+MTX) or the switch (TCZ+placebo [PBO]) strategy arm. 24- and 52-week data demonstrated clinical...