Clinicians accept own opinion of low disease activity over T2T in axial spondyloarthritis
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Key takeaways:
- Physicians often treated patients according to their own opinion rather than official treat-to-target indexes.
- Most patients with residual disease did not receive more intensive therapy.
In patients with residual axial spondyloarthritis disease activity, many physicians avoid strict adherence to treat-to-target guidelines in favor of low disease activity, based on their own opinion, as a treatment goal, according to data.
“The current Assessment of SpondyloArthritis international Society (ASAS)-EULAR recommendations advise to treat axial spondyloarthritis (axSpA) patients according to the ‘tight control’ (TC) and/or ‘treat-to-target’ (T2T) principles,” Janne W. Bolt, MD, of the Amsterdam Institute for Infection and Immunity, and colleagues wrote in Rheumatology. “Nevertheless, it is not yet known if these strategies have a positive effect on the long-term clinical outcomes of axSpA patients and a recent cluster-randomized trial [Tight Control in SpA (TICOSPA)] could not confirm a better clinical outcome for the use of T2T compared with conventional treatment strategies.
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“In contrast to the guidelines for rheumatoid arthritis, there is no unanimous composite index that is advised for T2T in axSpA,” they added. “For this reason, disease remission or low disease activity is currently the best possible choice, without further specifying composite indices or threshold values.”
To investigate residual disease activity in patients with axial SpA, based on physicians’ and patients opinion, as well as composite indices, compared with later treatment strategies, Bolt and colleagues instituted a cross-sectional, multicenter study of patients who completed a live visit or telephone consultation at a participating center. Patients were required to have a clinical diagnosis of radiographic or non-radiographic axial SpA for a minimum of 6 months prior to enrollment, and be aged 18 years or older.
Information including demographics, disease status and characteristics, current treatment methods and treatment histories were collected for each patient. Additionally, treating physicians were asked whether their patients were in remission or experiencing low disease activity, whether disease features were present, if therapies were changed, and whether and why the physician used a composite index to help make treatment decisions.
Patients also completed a survey that asked whether they believed their disease to be active or inactive, whether they suffered symptoms including fatigue, back pain, pelvic pain, peripheral joint or tendon pain or stiffness, and limited movement, whether they agreed with the treatment they received, and if they were satisfied with their current treatment. Finally, treatments for patients were checked to see if they were compliant with treat-to-target guidelines.
The study included 249 patients, of whom 46% were in remission according to their treating physician, while 37% had reached remission according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Among the 83 patients with residual disease activity remaining — according to the physician and a BASDAI greater than 3.5 — therapy was left unchanged in 60%. The reasons for leaving the treatment unchanged included physician-defined low disease activity — cited by 29% of physicians — or comorbidities — cited by 25%.
Based on retrospective treat-to-target assessments, physicians intensified therapy most often in patients with arthritis or inflammatory back pain. Meanwhile, patients with non-inflammatory musculoskeletal conditions often did not receive intensified therapy, according to the researchers.
“This study showed that in axSpA daily clinical practice there is a significant discrepancy between the physician’s opinion on disease activity and the BASDAI, a composite index that could be used for benchmarking in T2T,” Bolt and colleagues wrote. “Also, in contrast to the T2T principles, treatment adaptations in general were most often not steered by disease activity status according to the BASDAI, but by physician’s opinion on disease activity status. Achievement of low disease activity according to their own opinion was usually satisfactory for physicians as a treatment goal.”
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