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Too few RA patients get timely adjustment of DMARDs


Key clinical point: Prompt adjustment of DMARD therapy in response to persistent disease activity more rapidly gets RA under control.

Major finding: In 40% of patients who had persistent disease activity of this severity, clinicians waited more than the 90 days recommended by treat-to-target guidelines to adjust DMARDs.

Data source: A retrospective cohort study of 538 patients with RA having moderate to high disease activity.

Disclosures: One of the study authors received research funding from Genentech and is currently employed by AbbVie. The study registry used was funded by the National Institutes of Health and Genentech.

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Need stronger push to implement treat-to-target


Randomized controlled trials demonstrate that statin lipid–lowering drugs reduce repeat cardiovascular events. Based on this evidence, clinicians agree that the vast majority of patients should receive statin lipid-lowering drugs after a CV event, and that providers not prescribing statins to these patients are providing suboptimal care.

By analogy, the data provided in this new analysis by Shaw and her colleagues suggests that many rheumatologists are providing suboptimal care. Many randomized, controlled trials testing a treat-to-target (T2T) paradigm demonstrate the clinical benefits of changing treatments for patients with rheumatoid arthritis who are in moderate or high disease activity. Yet, this analysis found many patients do not change treatments despite poor disease control. While the current study does not examine the reasons for suboptimal care, some correlates include:

• Patient preference to not change treatment;

• Provider desire to give treatments more time to work; and

• Health system issues such as drug payment complexities.

Dr. Daniel H. Solomon, Brigham and Women's Hospital, Boston
Dr. Daniel H. Solomon
How can we overcome the clinical inertia that fights against following a T2T paradigm? T2T involves a complex interplay between patient and provider. It can be distilled to several features: 1) selecting a disease activity target in consultation with patients (typically remission or low); 2) measuring disease activity regularly; 3) deciding whether to maintain treatment or change based on whether the selected disease activity has been reached or maintained; and 4) patients and providers sharing the decision-making process to determine a target or treatment.

Continuing medical education may be necessary, but it is not a sufficient lever to push providers to implement T2T. Audit and feedback – providing individual providers with their performance metrics – alerts rheumatic disease providers when improvement is necessary. Yet, most providers need specific strategies within their practice to implement T2T. Collaborative learning between providers with a common purpose and coaches that understand the complexities of implementing T2T have been shown in the recently published TRACTION trial to produce improvements (Arthritis Rheumatol. 2017;69[7]:1374-80). The article by Shaw and her colleagues should sound the alarm to rheumatic disease providers: Care for RA needs improving if we want to produce optimal outcomes.

Daniel H. Solomon, MD, is a professor of medicine at Harvard University, and chief of the section of clinical sciences in the division of rheumatology at Brigham and Women’s Hospital, both in Boston. He has no relevant disclosures.




Adjustment of disease-modifying antirheumatic drug (DMARD) therapy is not happening quickly enough for a substantial minority of rheumatoid arthritis patients with moderate to high disease activity, according to the findings of a registry study that is the first to evaluate this association.

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