Expert Perspective: Toward Treat-to-Target Management in Adult Idiopathic Inflammatory Myopathies

Treat-to-target (T2T) has transformed the management of several rheumatic diseases through predefined therapeutic goals, structured disease assessment, and timely treatment adjustment. Despite major advances in the understanding and treatment of idiopathic inflammatory myopathies (IIM), a formal T2T framework for adult IIM has not yet been established. Given the substantial burden of persistent disease activity, treatment-related toxicity, and irreversible organ damage, together with recent advances in IIM therapeutics, there is increasing rationale for adopting a structured, target-oriented approach in these disorders. In this expert perspective, we discuss the principles of T2T in adult IIM and review the evidence supporting its application. We examine key challenges that limit implementation, including the absence of validated definitions for remission and low disease activity, limitations of existing disease activity measures, the heterogeneity of clinical manifestations across organ systems, and the difficulty of distinguishing active inflammation from irreversible damage. We further discuss the role of skin, pulmonary, and patient-reported outcome assessments within a domain-based monitoring framework, together with practical considerations regarding biomarker interpretation and individualized treatment targets. Drawing on experience from other systemic autoimmune rheumatic diseases, we propose a pragmatic framework for T2T implementation in adult IIM. This approach emphasizes measurable treatment goals, structured multidimensional assessment, shared decision-making, and adaptation of targets according to disease phenotype, organ involvement, and accumulated damage. While important knowledge gaps remain, particularly regarding disease state definitions and outcome measure standardization, a T2T strategy may improve disease control, reduce long-term morbidity, and provide a framework for clinical care and research in IIM.