Treating juvenile idiopathic arthritis to target: what is the optimal target definition to reach all goals?

Abstract

In 2018, an international Task Force formulated recommendations for treating Juvenile Idiopathic Arthritis (JIA) to target. The Task Force has not yet resolved three issues. The first issue is the lack of a single "best" target. The Task Force decided not to recommend the use of a specific instrument to assess inactive disease or remission. Recent studies underscore the use of a broad target definition. The second issue is the basic assumption that a treatment aggressively aimed at the target will have 'domino effects' on other treatment goals as well. Thus far, this assumption was not confirmed for pain, fatigue and stiffness. The third issue is shared decision-making, and the role of individual patient targets. Nowadays, patients and parents should have a more active role in choosing targets and their personal treatment goals. In our department the electronic medical records have been restructured in such a way that the patient's personal treatment goals with a target date appears on the front page. The visualization of their specific personal goals helps us to have meaningful discussions on the individualized treatment strategy and to share decisions. In conclusion, a joint treat to target (T2T) strategy is a promising approach for JIA. The Task Force formulated valuable overarching principles and a first version of recommendations. However, implementation of T2T needs to capture more than just inactive disease. Patients and parents should have an active role in choosing personal targets as well.

Treat‐to‐Target From the Patient Perspective Is Bowling for a Perfect Strike

“…For JIA, the ultimate treatment goals have been described as follows: "to control signs and symptoms; to prevent structural damage; to avoid comorbid conditions and drug toxicities; and to optimise function, growth and development, quality of life, and social participation" (3). From a patient perspective, the acknowledgment of all goals, including those related to pain, fatigue, activities of daily living, and social participation, is highly valued (5,6).…”

“…Decisions regarding disease management are based almost solely on disease activity scores, and on use of pharmaceutical treatments to affect these scores. The recommendations do not take into account other patient-relevant outcomes, e.g., pain, fatigue, morning stiffness, and daily functioning, some of which may require other interventions, e.g., exercise or physical therapy, specialized surgery, or psychosocial support, rather than a change in the pharmaceutical treatment (5,6,8).…”

“…Ultimately, well-conducted strategic trials will be needed to demonstrate the presumed superiority of the treat-to-target strategies with regard to all relevant goals. Unfortunately, thus far in most treat-to-target-trials a measure of disease activity or "biological remission" has been the main, or even the single, end point (5)(6)(7)(8)(9)(10)(11)(12)14). From the patient perspective, this is clearly insufficient to judge success.…”

Longitudinal assessment of racial disparities in juvenile idiopathic arthritis disease activity in a treat-to-target intervention

“…Similarly, there is more recent evidence to suggest that TTT strategies result in better disease control in children with JIA compared to unstructured treatment [ 13 , 14 ]. Initial recommendations for the adoption of TTT principles in JIA were put forth by an international task force [ 15 , 16 ]. We have previously described the implementation of a TTT approach for polyarticular JIA in a real-world clinical setting with standardized, real-time outcome measurement augmented by clinical decision support (CDS) [ 17 ].…”

Peculiarities of the state of the cardiovascular system in patients with juvenile idiopathic arthritis

“…Дотримуючись стратегії лікування «Treat to target» [10], можна утримувати прийнятний рівень функціональної недостатності з боку опорно рухового апарату. Проте в дорослих хво рих на ревматоїдний артрит і в дорослих хворих на ЮІА в структурі смертності пацієнтів перше місце посідають захворювання серцево судин ної системи (ССС) [6].…”