Treat-to-target: new therapeutic approach

The treatment goal for an inflammatory disease is to stop or decrease symptoms as soon as possible. The problem with traditional treatment is that there is minimal ongoing assessment. As a result, months, or even years, go by without a patient getting the treatment that really helps. The new treat-to-target approach is more strategic, meeting specific targets and making adjustments until the treatment goal is achieved.

What is treat-to-target?

Treat-to-target is a strategy for clinicians to use which involves setting goals and monitoring progress along the way. The aim of this method is to lower disease activity, working towards remission. This is defined as the absence of signs and symptoms related to inflammatory disease activity. If the target is not reached, medications or doses are adjusted to meet a predetermined protocol. This thorough process of assessment and readjustment continues until the goal is achieved.

To be more specific, the treat-to-target method requires that the health practitioner tracks and measures the disease activity every one to three months, until the outcome is reached. After which the disease activity is measured every three to six months. During this period, if the disease worsens or is not sustaining a healthy rate, the treatment should be adjusted. It focuses on treating the disease aggressively from the start, instead of trying light medication at first, with the goal of decreasing the severity of the disease over the long term.

Treat-to-target components

There are four main components of the treat-to-target approach which should be followed by physicians. This step-by-step approach can provide an ongoing guide for assessing patient progress.

Target setting

Medical conditions can typically be assessed by a variety of lab tests or physical symptoms. During the target setting, the doctor and patient work together to determine which specific target to aim for. For example, if a person is diagnosed with rheumatoid arthritis (RA), the goal may be to lower inflammation by means of medication. This could be tested every few months by measuring a lab value such as C-reactive protein (a measurement of inflammation) and changing the medication until it’s brought into a normal range.

Testing

A main part of the treat-to-target plan is to have regular testing. This helps the healthcare provider evaluate and monitor the progress to assess if the goal is being met. During this phase, a clear goal is also helpful. For instance, getting that C-reactive protein lab test ordered every month and setting up an appointment to review the lab values.

Treatment changes

If the treatment goals of specific symptom reduction or lab values are not progressing, then the treatment is changed. This may mean increasing medication dosage or switching to another medication. This is also an excellent area to consider lifestyle changes such as dietary changes, exercise, or improving sleep. Research suggests that lifestyle changes can have a big impact on diseases such as inflammatory ones.

Treatment decision making

Together, the physician and patient make choices for which treatments take priorities. The physician offers expertise while the patient expresses what works, doesn’t work, and what they are willing or able to do. This can help determine any necessary changes in treatment and assessment of long-term benefits.

Treat-to-target vs. routine care

The traditional way of treating conditions often involves medication being prescribed based on clinical judgment. So physicians would consider the patient’s current condition, symptoms, and medical history, then use their knowledge of medications and interactions in order to prescribe a treatment plan. Follow-up and testing is likely less frequent with traditional methods. According to the Arthritis Foundation, as low as a 50% change in disease activity would be considered to be successful, whereas treat-to-target aims for higher standards.

A consideration in regards to the treat-to-target method is that when a patient takes other medications, has other symptoms, or limitations for the treatments, this can skew the results. A downfall of the treat-to-target method is that physicians report not using it because of lack of time and appointment availability. Some also believe that patients don’t want to make switches to medications so often.

Treat-to-target conditions and results

Treat-to-target can be applied to almost every condition such as insulin-based diabetes or heart disease, but the current focus includes inflammatory conditions such as inflammatory bowel disease (IBD) and rheumatoid arthritis (RA).

Inflammatory bowel disease (IBD)

Inflammatory bowel disease (IBD) is an extremely complex condition, impacted by a variety of factors including a combination of genetics and the environment. When it comes to IBD, treat-to-target can help heal the gut, prevent complications associated with long-term inflammation, and improve patient outcomes. Potential defined targets include mucosal healing, normalizing biomarkers, and improving imaging.

The Randomized Evaluation of an Algorithm for Crohn’s Treatment (REACT) study used the treat-to-target approach to evaluate early biological therapy, compared to conventional therapy. After 12 months, the symptom responses were similar but at 24-months, the rate of surgeries, hospitalizations, or serious disease-related complications were significantly lower in the treat-to-target group.

Rheumatoid arthritis (RA)

Similar to IBD, rheumatoid arthritis (RA) is an autoimmune and inflammatory disease in which the immune system attacks health cells by mistake. With RA, the immune system commonly attacks joints in the hands, wrists, and knees. This leads to chronic pain, decreased balance and some misshapeness. Just like IBD, this complex condition can be difficult to treat which is why treat-to-target may be a good option.

Current evidence from clinical trials and meta-analysis, support that the treat-to-target approach has important clinical benefits in patients with RA when compared to routine care. The Dutch Rheumatoid Arthritis Monitoring (DREAM) trial found that remission rates, improved physical function, and better quality of life were achievable both during the first year and were sustained at a three-year follow up.

Treat-to-target and digital therapeutics

As healthcare is making a shift into digital solutions and patients are becoming more empowered to participate in their treatment plans, the need for digital therapeutics is increasing. Digital therapeutics includes technology-based products and services that are used for healthcare and wellness services. It encompasses evidence-based soft-ware-driven therapeutic interventions as a means to prevent or manage disease. It has been showing promising results when it comes to treatment plan and medication adherence. An example is an app that gives notification reminders for patients to take medications.

Digital therapeutics can also be an ideal method for helping doctors integrate and utilize the treat-to-target approach. For example, during the initial treat-to-target, target setting phase, a patient can add their determined goal to a digital therapeutics platform. There can be reminders or education provided to help the patient keep up with any lifestyle habits, then can remind the patients when it’s time to make an appointment to test. This also offers the patient an opportunity to asses how the treatment is working, further increasing the pace at which the condition can be treated.

Nori Health as treat-to-target

Nori Health is a digital therapeutic company which helps promote the treat-to-target method by means of solving the challenge that physicians lack time and appointment availability. Nori Health helps bridge the gap between appointments by means of offering support and condition assessment. Through a 6-week program, patients will be making healthy lifestyle changes that support medication protocol. Learn more about Nori Health and how it can support the treat-to-target method: Nori Health.

This article has been written by Lisa Booth, registered dietitian and nutritionist, and co-founder of Nori Health. Content is based on her professional knowledge and our collection of 100+ scientific research study papers.