THU0138 RHEUMATOLOGISTS’ ADHERENCE TO THE TREAT-TO-TARGET PRINCIPLE IN EARLY RA PATIENTS WITHIN THE PRAGMATIC CARERA TRIAL: ROOM FOR IMPROVEMENT?
Authors: Veerle Stouten, Diederik De Cock, Sofia Pazmino, Kristien Van der Elst, Johan Joly, Delphine Bertrand, Rene Westhovens, Patrick Verschueren
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Treating to a predefined target is a principle adopted in guidelines to treat rheumatoid arthritis (RA). It is currently the most efficient strategy to control disease activity, but its implementation in daily clinical practice remains challenging. <h3>Objectives</h3> To evaluate rheumatologists’ adherence to a treat-to-target (T2T) approach at a threshold of low disease activity (DAS28CRP≤3.2) in patients with early RA during the 2-year Care in early RA (CareRA) study. <h3>Methods</h3> CareRA is an investigator-initiated pragmatic multicentre trial, in which patients with early RA and naïve to conventional synthetic disease modifying anti-rheumatic drugs (csDMARD) were included (n=379). Participants were randomized to different remission induction schemes consisting of a csDMARD combination or methotrexate (MTX) monotherapy with and without a prednisone tapering down scheme. Following the T2T approach, specific treatment adaptations had to be performed in case of DAS28CRP&gt;3.2 during the first study year, unless a predefined reason not to intensify treatment was provided. As first step, dose of MTX had to be increased from 15mg to 20mg weekly. As second step, dose of the other csDMARD was escalated in the combination arms and leflunomide was added in the MTX monotherapy arms. From week (w)52 onwards, further T2T was advised but type of treatment adaptation was left at the rheumatologists’ discretion. Adherence to this T2T approach was defined as performing a dose escalation or changing/adding DMARD medication in case of DAS28CRP&gt;3.2 and was evaluated at every study visit during 2 years. Additionally, remission (DAS28CRP&lt;2.6) rates at w104 were compared between patients in which T2T was applied at every visit and patients not always treated to target. Only data from patients for which DAS28-CRP scores were available were taken into account to evaluate the low disease activity state. <h3>Results</h3> The proportion of patients with DAS28CRP&gt;3.2 was 26% (93/365) at w8, but decreased to a stable average of 16% on the following visits and further diminished to 10% (30/303) at w104. The frequency of T2T adherence in these patients varied from 59% (55/93) at w8 to 17% (5/30) at w104 (Figure 1). The most frequent reason not to intensify treatment during the first study year was that rheumatologists considered the disease already well-controlled. This reason was reported in 50% of non-adherent cases at w8, in 15% at w16, 14% at w28, and 24% at w40. The second most frequently given reason for non-adherence during the first study year was that giving glucocorticoids or NSAIDs temporarily was preferred over changing DMARDs, as reported in 3% of cases at w8, 15% at w16, 27% at w28, and 35% at w40. T2T was applied at all visits in 41 out of 110 (37%) patients needing at least 1 adaptation during the 2-year trial. Of these 41 patients, 36 (88%) were in remission at w104, while of the 69 patients not always treated to the T2T principle, 40 (58%) were in remission at the end of the 2-year trial (p=0.001). <h3>Conclusion</h3> This study shows the difficulty of applying T2T strictly, both with and without a fixed protocol to follow. In less than half of patients theoretically in need of a treatment adaptation, treatment was intensified at all visits during the first 2 years of treatment. In the majority of cases rheumatologists gave as reason for overruling the T2T guidance that they estimated disease activity to be sufficiently controlled. However, patients in which the T2T principle was applied strictly, showed higher remission rates after 2 years of treatment. <h3>Disclosure of Interests</h3> Veerle Stouten: None declared, Diederik De Cock: None declared, Sofia Pazmino: None declared, Kristien Van der Elst: None declared, Johan Joly: None declared, Delphine Bertrand: None declared, Rene Westhovens Grant/research support from: Bristol-Myers Squibb, Consultant for: Celltrion, Galapagos-Gilead, Patrick Verschueren Grant/research support from: Unrestricted Pfizer Grant for Early RA research