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Treat-to-target approach emerging in axial spondyloarthritis

Presented by
Dr Pedro Machado, University College London Hospitals, United Kingdom
EULAR 2019
Observational evidence suggests that a treat-to-target (T2T) approach might be beneficial in axial spondyloarthritis. However, data from a prospective randomised study showing the efficacy of a T2T strategy compared to routine care are currently lacking. Additionally, there is no consensus about what should be measured and its specific target. These were the take-home messages presented by Dr Pedro Machado (University College London Hospitals, United Kingdom) discussing the pros and cons of adopting a T2T strategy in the management of axial spondyloarthritis [1].

The availability of biologic therapies has improved the clinical outcomes of patients with axial spondyloarthritis, which has raised the question if there is a role for T2T. Dr Machado explained that the concept involves changing or escalating therapy according to a predefined target, under the assumption that this may lead to better outcome compared to routine care. T2T is not only well established in non-rheumatic diseases, but has been proven efficient in patients with rheumatoid and psoriatic arthritis, with evidence from multiple studies such as the Tight Control of Rheumatoid Arthritis (TICORA) and the Tight Control in Psoriatic Arthritis (TICOPA) trials. Whether the approach can work in axial spondyloarthritis is open to debate. One of the main counterarguments against using T2T in axial spondyloarthritis is lack of agreement on what to target.

Despite lack of consensus, Dr Machado observed that achieving clinical remission or inactive disease according to the ASDAS are the most likely targets. Clinical remission may help improve patients’ functional outcomes and quality of life. Achieving inactive disease (ASDAS <2.1 or BASDAI <4) may improve structural and functional outcomes and stop the development of radiographic spine damage. Furthermore, he argued that there is a need for being more ambitious. Patients with high disease activity, regardless of sufficient standard treatment, should be escalated to treatment with biologic disease-modifying antirheumatic drugs (bDMARDs).

Evidence is currently lacking to support a T2T approach in axial spondyloarthritis, but The Tight Control in Spondyloarthritis (TICOSPA) trial –of which results are expected next year– is in progress. Altogether, observational evidence supports a T2T strategy in axial spondyloarthritis despite a missing randomised trial. This was also the view of an international task force who published their recommendations for a T2T approach in axial spondyloarthritis [2]. The cost-effectiveness of a T2T strategy in clinical practice is another issue that needs to be assessed. Unlike RA, where the target invariably is the accessible and visible small joint swelling and inflammation, the hidden entheseal and osteitic pathology in the spine -that is difficult to differentiate from mechanical/degenerative pathology- means that the clinical metrologists are still “flying in the dark” and the difficultly in visualisation of the target remains an ongoing issue.

  1. Machado PM, Deodhar A. Curr Opin Rheumatol. 2019 Jul;31(4):344-348.
  2. Smolen JS, et al. Ann Rheum Dis. 2018 Jan;77(1):3-17.

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