Update from the T2T RA Global Summit

The updated T2T recommendations were recently published in ARD, 5 years after the first set.

The spirit is still the same with minor but important considerations:

• In the overarching principles, there is more emphasis on Work-related activities; this was emphasized at the request of patients who feel that it is a very important outcome

• The order of certain recommendations was changed to better reflect the spirit and improve the flow of recommendations

• New references were added to support the concept and this improved the level of evidence of several recommendations compared to the 2010 set. Of note is the Canadian OPTIMIZATION trial with Janet Pope as the senior investigator. This trial is actually the only T2T trial in established RA disease.

There was a discussion regarding the Preferred Composite Outcome Measure to be used: While DAS or DAS28 were the most widely used outcomes that led to development of the T2T, the ACR/EULAR has recommended the Boolean definition of remission or the composite index SDAI. There is evidence that a more stringent definition of remission leads to improved functional and radiographic outcomes as well as improved outcomes including survival and cardiovascular events.

One drawback would be the tendency for overtreatment in order to reach the more stringent definition in individual patients whose scores are driven by NON-inflammatory components. This is where both the physician and patient have to agree that a lesser level such as LDA is appropriate, especially if the patient has other comorbidities that could impact scoring or limit the escalation of medication.

One other important question: Do we need to monitor radiographic remission? The overwhelming response is PROBABLY NOT. There is extensive evidence that patients who achieve the more stringent definition of remission (Boolean or SDAI) do not develop progressive structural damage. Moreover, patients treated with anti-TNF agents do not accrue significant structural damage even when in LDA.

US and MRI are not yet ready for routine use to monitor synovitis. In patients in clinical remission based on the Boolean definition or SDAI, residual US power Doppler activity does not necessarily lead to increased radiographic damage. Their role in predicting clinical flares, especially in patients undergoing de-medication, is being investigated.

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