Overview and analysis of treat-to-target trials in rheumatoid arthritis reporting on remission

To present an updated overview of tight control studies with a fixed treatment target ('treat-to-target'), reporting on (sustained) remission in rheumatoid arthritis (RA).

A search of the electronic databases Medline (PubMed), Embase and Cochrane was performed in July 2012 to identify trials and studies addressing tight control with treat-to-target reporting on (sustained) remission, regardless of definition or duration. Next to a narrative overview of the identified studies, a formal meta-analysis was performed pooling study results of studies comparing the effects of a tight control and treat-to-target strategy arm with those of a usual care strategy.

Thirteen studies were found, 4 comparing effects of tight control to those of usual care, 1 comparing the effects of 2 strategies with the same DMARDs but using different treatment targets, and 8 comparing the effects of tight control strategies with different DMARDs but with the same treatment target. Remission rates differed over a wide range in these studies, but in general were not higher in studies applying a biological DMARD from start compared to studies with initial conventional DMARD strategies. The meta-analysis of the 4 studies comparing tight control versus usual care shows that applying a treat to (any) target strategy appeared to approximately double the remission rates of the participating early RA patients.

The trials comparing tight control arms show in general that the more intensive the strategy, the more strict the treatment aim and the more tight the tight control, the better the remission rates. It does not appear obligatory to start with a biological DMARD to get good results in tight control studies.