The Challenge with Treat to Target Therapy

First off, let me say that treating to a target is an excellent idea. We all have our targets, and although they may differ, treating to a target certainly benefits the patient. But we've all faced the common scenario when a patient comes into the office with smouldering RA and states "I am doing OK." We all know this patient scenio with a few swollen joints, a low-grade grumbling CRP, and a slight uptick in the HAQ. They're doing well now but what about in 10 years? When we go on to discuss other treatment options, we're often faced with hesitation and resistance - sometimes this is our own inner hesitation not to make things worse and sometimes it's resistance from the patient. With DMARDs it was easy to just add-on but with biologics and smaller molecules this is no longer the case and we must contemplate an actual change in therapy. Have you ever wondered why, from a fundamental perspective, this is met with resistance?

Let's start with a couple of scenarios:

Question 1: Which of the following would you prefer?

Choice A: A certain win of $250, versus
Choice B: A 25% chance to win $1000 or a 75% chance to win nothing?

Question 2: Which of the following would you prefer?

Choice A: A certain loss of $750, versus
Choice B: A 75% chance to lose nothing or a 25% chance to lose $1000?

The first question is grounded in gain. Most people will pick Choice A and take the certainty of winning $250 over risking it and losing. The second question is grounded in loss. Most people will pick Choice B and gamble to lose nothing. Why?

It's called loss aversion, which is a human tendency to strongly prefer avoiding a loss compared to receiving a gain. This is hard-wired into our DNA and consistently explains irrational decisions in economics and healthcare. There are several theories on why humans are so averse to loss. One is based on the evolutionary advantage of maximizing opportunities while minimizing threats. Even our metabolism is hard-wired to hold on to what we have – just think of how our body stores excess calories!

Loss aversion can be both helpful and harmful when it comes to making health-related decisions. When treating to a target there is a risk involved with giving up a treatment that has worked to some extent. So-called loss aversion.

How can we overcome loss aversion in RA?

Here are two strategies to overcome loss aversion, i.e., to minimize the chances of loss of response. The first strategy is to try switching to another drug for a period of time, acknowledging that if it doesn't work out, we can go back to the current treatment. This can be facilitated by product samples – the patient can walk away with a short-term supply of another treatment option and test it out.

The second strategy is to change to an agent with a different mechanism of action. For example, if the patient is taking an anti-TNF, rather than switch to another anti-TNF, we could try a medication in a different class that works in a completely different way.

More reports from ACR 2016