title: Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force.
abstract: BACKGROUND
  Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.
  
  
  OBJECTIVE
  To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.
  
  
  METHODS
  A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.
  
  
  RESULTS
  The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).
  
  
  CONCLUSIONS
  The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.
authors.affiliation: Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria 2nd Department of Medicine, Hietzing Hospital, Vienna, Austria.
authors.forename: Josef S
authors.initials: JS
authors.lastname: Smolen
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Ferdinand C
authors.initials: FC
authors.lastname: Breedveld
authors.affiliation: Department of Rheumatology, Clinical Immunology Free University and Humboldt University, Charité-University Medicine, Berlin, Germany.
authors.forename: Gerd R
authors.initials: GR
authors.lastname: Burmester
authors.affiliation: Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, USA.
authors.forename: Vivian
authors.initials: V
authors.lastname: Bykerk
authors.affiliation: Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France.
authors.forename: Maxime
authors.initials: M
authors.lastname: Dougados
authors.affiliation: Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Emery
authors.affiliation: Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
authors.forename: Tore K
authors.initials: TK
authors.lastname: Kvien
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: M Victoria
authors.initials: MV
authors.lastname: Navarro-Compán
authors.affiliation: Susan Oliver Associates, North Devon, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Oliver
authors.affiliation: 2nd Department of Medicine, Hietzing Hospital, Vienna, Austria.
authors.forename: Monika
authors.initials: M
authors.lastname: Schoels
authors.affiliation: EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
authors.forename: Marieke
authors.initials: M
authors.lastname: Scholte-Voshaar
authors.affiliation: Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
authors.forename: Tanja
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authors.lastname: Stamm
authors.affiliation: Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
authors.forename: Michaela
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authors.lastname: Stoffer
authors.affiliation: Division of Rheumatology, Department of internal Medicine, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Tsutomu
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authors.lastname: Takeuchi
authors.affiliation: Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
authors.forename: Daniel
authors.initials: D
authors.lastname: Aletaha
authors.affiliation: Rheumatology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain.
authors.forename: Jose Louis
authors.initials: JL
authors.lastname: Andreu
authors.affiliation: Department of Medicine III, University Medical Center TU Dresden, Dresden, Germany.
authors.forename: Martin
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authors.lastname: Aringer
authors.affiliation: Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
authors.forename: Martin
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authors.lastname: Bergman
authors.affiliation: EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
authors.forename: Neil
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authors.lastname: Betteridge
authors.affiliation: Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, and VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Hans
authors.initials: H
authors.lastname: Bijlsma
authors.affiliation: Division of Rheumatology, Department of Medicine, Johann-Wolfgang-Goethe University Frankfurt, German.
authors.forename: Harald
authors.initials: H
authors.lastname: Burkhardt
authors.affiliation: Centro de Investigación Clínica de Morelia, Morelia, Michoacán, Mexico.
authors.forename: Mario
authors.identifier: http://orcid.org/0000-0002-2731-9180
authors.initials: M
authors.lastname: Cardiel
authors.affiliation: Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France.
authors.forename: Bernard
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authors.lastname: Combe
authors.affiliation: Pôle de Recherche en Rhumatologie, Institut de Recherche Experimentale et Clinique, Université Catholique de Louvain and Cliniques Universitaires Saint-Luc, Brussels, Belgium.
authors.forename: Patrick
authors.initials: P
authors.lastname: Durez
authors.affiliation: Rheumatology Research Unit, Instituto de de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal Rheumatology Department, Lisbon Academic Medical Centre, Lisbon, Portugal.
authors.forename: Joao Eurico
authors.initials: JE
authors.lastname: Fonseca
authors.affiliation: Weill Medical College, Cornell University Hospital for Special Surgery, New York, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Gibofsky
authors.affiliation: Rheumatology Unit, Santiago University Clinical Hospital, Santiago de Compostela, Spain.
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Gomez-Reino
authors.affiliation: Division of Rheumatology, Medical University of Graz, Graz, Austria.
authors.forename: Winfried
authors.initials: W
authors.lastname: Graninger
authors.affiliation: Department of Medicine, Central Hospital, Jyväskylä, Finland.
authors.forename: Pekka
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authors.lastname: Hannonen
authors.affiliation: Institut de Rhumatologie de Montréal, Quebec, Canada.
authors.forename: Boulos
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authors.affiliation: EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
authors.forename: Marios
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authors.lastname: Kouloumas
authors.affiliation: Academic Medical Center, University of Amsterdam, Amsterdam, and Atrium Medical Center, Heerlen, The Netherlands.
authors.forename: Robert
authors.initials: R
authors.lastname: Landewe
authors.affiliation: University Hospital La Paz, Madrid, Spain.
authors.forename: Emilio
authors.initials: E
authors.lastname: Martin-Mola
authors.affiliation: University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Nash
authors.affiliation: Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Mikkel
authors.initials: M
authors.lastname: Ostergaard
authors.affiliation: Rheumatology Clinical Research Unit, School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Östör
authors.affiliation: EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
authors.forename: Pam
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authors.lastname: Richards
authors.affiliation: Department of Rheumatology, Central Hospital, Jyväskylä, Finland.
authors.forename: Tuulikki
authors.initials: T
authors.lastname: Sokka-Isler
authors.affiliation: Division of Rheumatology, Southlake Regional Health Centre, Newarket, Ontario, Canada.
authors.forename: Carter
authors.initials: C
authors.lastname: Thorne
authors.affiliation: Department of Pathophysiology, School of Medicine, University of Athens, Greece.
authors.forename: Athanasios G
authors.initials: AG
authors.lastname: Tzioufas
authors.affiliation: Rheumatology Clinic, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Ronald
authors.initials: R
authors.lastname: van Vollenhoven
authors.affiliation: EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland.
authors.forename: Martinus
authors.initials: M
authors.lastname: de Wit
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: Desirée
authors.identifier: http://orcid.org/0000-0002-5781-158X
authors.initials: D
authors.lastname: van der Heijde
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D015897:Comorbidity; D019317:Evidence-Based Medicine; D006801:Humans; D060046:Maintenance Chemotherapy; D010347:Patient Care Planning; D010358:Patient Participation; D012074:Remission Induction; D012720:Severity of Illness Index; D009626:Terminology as Topic
chemical_list: D018501:Antirheumatic Agents
keywords: Disease Activity; Early Rheumatoid Arthritis; Outcomes research; Rheumatoid Arthritis; Treatment