The impact of treat to target on 1 year real world outcomes in patients with rheumatoid arthritis

Background

Treat-to-target (T2T) recommendations are designed to inform rheumatologists and patients about strategies to enable optimal outcomes in RA based on evidence and expert opinion. This real-world, prospective audit has a patient cohort with >12 months of follow-up data, allowing assessment of the impact of T2T.

Methods

Since April 2012, 48 NHS rheumatology services have enrolled newly diagnosed RA patients prospectively into the T2T audit. Data on disease management, treatments and outcomes are collected when the patient is reviewed in clinic. Here we present results of a cohort of patients who have been followed up for 12 months from diagnosis.

Results

By August 2015, 1470 patients had been enrolled into the audit, with a cohort of 460 (31%) with data at ≥ 12 months from diagnosis. Within this cohort, the median age at symptom onset was 61 years, 32% were male, 74% (342/460) had a target of remission [28-joint DAS (DAS28) <2.6] and 7% (33/460) had a target of low disease activity (LDA; DAS28 2.6–<3.2) set at diagnosis. Where data were available, 45% (135/301) had DAS28 performed at each visit. A total of 210/342 patients with a DAS28 remission target and 21/33 with an LDA target had both baseline and 12 month DAS28. The mean number of visits over a year was 4 (S.D. 3.1). After 12 months, 56% (182/325), 35% (114/325) and 5% (15/325) of patients were on DMARD mono, dual and triple therapy, respectively. A total of 117/210 (56%) achieved remission and 6/21 (29%) achieved LDA. The median DAS28 achieved was 2.38 and 3.89 in the remission and LDAS groups, respectively. Twenty-one per cent (51/248) of patients were in sustained remission (three consecutive visits) at 1 year. Of these, 59% (30/51) received monotherapy, 39% (20/51) dual therapy and 0% (0/51) triple therapy. Nine per cent (42/460) of patients were eligible for a biologic (two consecutive DASs >5.1, failure of two DMARDS); of these, 45% (19/42) were prescribed a biologic. Among the cohort of patients <60 years of age, the percentage in employment changed from 57% (125/221) at baseline to 46% (77/169) at 12 months. Among those ≥60 years of age, 8% (19/239) and 4% (7/156) were employed at baseline and at 12 months, respectively. There was a reduction in patient-reported work difficulties from 40% (34/84) at baseline to 16% (8/49) at 12 months.

Conclusions 

More than 50% of patients in the remission target group were in remission by 12 months; however, despite the T2T approach, there is still an unmet need in terms of achieving sustained remission. This is highlighted by relatively low numbers of DAS28 assessments, triple therapy rarely being introduced before 12 months and the proportion of biologic-eligible patients not receiving them. It would be interesting to compare the employment data against a cohort treated with conventional strategies to determine the societal and patient impact of T2T in RA.