For someone living with rheumatoid arthritis (RA), the dream isn’t just less pain-it’s remission. Not just a temporary break from flare-ups, but a real, sustained state where the disease is quiet, joints are protected, and daily life isn’t ruled by stiffness or fatigue. For years, doctors treated RA by adjusting meds based on how a patient felt or how bad things looked at a single visit. That changed. Today, the gold standard isn’t guesswork-it’s treat-to-target (T2T). And the data shows it works.
What Treat-to-Target Really Means
Treat-to-target isn’t a new drug. It’s a new way of thinking. Instead of waiting for symptoms to get worse before acting, T2T sets a clear, measurable goal-usually remission (no signs of active disease) or at least low disease activity. Then, every step of treatment is guided by that target. If you’re not getting closer to it within 3 months, the plan changes. No delays. No "let’s wait and see." This approach is backed by over a decade of hard evidence. The DREAM trial in the Netherlands, which tracked 500+ early RA patients, found that 58% reached remission after a year using T2T. Compare that to traditional care, where only about 30% did. The BeSt trial showed similar results: 61% remission with T2T versus 37% with routine care after two years. These aren’t small improvements. They’re life-changing.How Do You Know If You’re in Remission?
You can’t just rely on how you feel. That’s why T2T uses objective tools. The most common one is the DAS28-a score based on 28 joints, blood markers like CRP or ESR, and how you report your overall health. A DAS28 score below 2.6 means remission. Between 2.6 and 3.2? Low disease activity. Anything above 3.2 means you’re still in active disease and need a change. Other tools like the CDAI and SDAI are also used, especially in North America. But DAS28 is the most widely adopted because it’s simple, reliable, and has been validated in tens of thousands of patients. Your rheumatologist should be measuring this at every visit when your disease is active-every 1 to 3 months. Once you’re stable in remission, it drops to every 3 to 6 months.The Medication Roadmap: From Methotrexate to Biologics
T2T isn’t just about measuring-it’s about acting fast. The treatment ladder is clear:- Methotrexate (10-25 mg/week) is the first step for nearly everyone. It’s cheap, effective, and the backbone of RA treatment.
- If you’re not improving after 3 months, add another conventional DMARD-like sulfasalazine or hydroxychloroquine. Triple therapy (methotrexate + sulfasalazine + hydroxychloroquine) is surprisingly effective and often underused.
- If you still haven’t hit your target, it’s time for a biologic or JAK inhibitor. These include TNF blockers like adalimumab or etanercept, IL-6 inhibitors like tocilizumab, or JAK inhibitors like baricitinib and upadacitinib.
Real-World Success: What Patients Are Saying
The numbers are strong, but real stories make it real. One patient from Perth, diagnosed in 2021, struggled for three years with flares and fatigue. Her previous rheumatologist didn’t track DAS28. When she switched to a clinic using T2T, they started her on methotrexate, added sulfasalazine after 2 months, and switched to a JAK inhibitor at 4 months when she wasn’t improving. She reached remission by month 6. "I haven’t had a flare since," she said. "I can hold my grandkids now." On patient forums like CreakyJoints and MyRheumaTeam, common themes emerge: "My doctor finally started checking my labs every visit," or "I thought I was doing everything right-but I wasn’t being monitored." The biggest complaint? "They say they use T2T, but they only check my CRP once a year." That’s the gap. Guidelines say check every 1-3 months. But a 2020 ACR survey found only 58% of rheumatologists actually use standardized scores at every visit. Without consistent measurement, T2T doesn’t work.Why It’s Not Working Everywhere
T2T works-but only if it’s done right. The biggest barriers aren’t medical. They’re practical.- Time and resources: Measuring joints, calculating scores, adjusting meds-this takes more time than a 10-minute visit.
- Access to drugs: Biologics and JAK inhibitors are expensive. In low-income countries, less than 25% of patients even get access to them.
- Doctor training: Not every rheumatologist was trained in T2T protocols. Some still rely on old habits.
- Patient expectations: Some patients feel like failures if they don’t reach remission. But not everyone can. That’s why the 2022 EULAR update now says: if remission isn’t possible, aim for low disease activity and focus on quality of life.
What’s Next? Digital Tools and Personalized Targets
The future of T2T is getting smarter. Trials like DART are testing smartphone apps that let patients log pain, swelling, and fatigue daily. The app then sends alerts to the clinic if things are trending upward-before the next appointment. Imagine getting a text: "Your joint pain scores have risen. Let’s schedule a check-in." Another big shift? Using biomarkers to predict who will respond to which drug. The RACAT trial in 2023 showed that combining T2T with early blood tests to match patients to the right biologic pushed remission rates to 68% at one year. Experts like Dr. Iain McInnes, president of EULAR, predict that within five years, T2T will use genetic and protein data to choose the best drug before the first dose. No trial-and-error. Just precision.What You Can Do Right Now
If you have RA, here’s how to make T2T work for you:- Ask your rheumatologist: "What’s my DAS28 score? What’s our target?" If they don’t know or don’t track it, ask for a referral to a clinic that does.
- Request a written plan: "If I’m not at target in 3 months, what’s the next step?" Get it in writing.
- Track your own symptoms. Use a simple notebook or app. Note which joints hurt, how tired you are, and if you had morning stiffness.
- Don’t stop meds because you feel better. Remission doesn’t mean cured. Stopping treatment often leads to flare-ups.
- If you’re not hitting your target after 3 months, don’t wait. Push for a change. Your joints are still at risk.
Final Thought: It’s Not About Perfection
Not everyone will reach remission. And that’s okay. The goal isn’t to be perfect-it’s to be better. To move from constant pain to occasional stiffness. From being housebound to walking the dog. From fear of flare-ups to confidence in your plan. T2T doesn’t promise miracles. But it gives you a fighting chance. And for a disease that once meant lifelong disability, that’s everything.Can rheumatoid arthritis go into remission without medication?
In rare cases, some patients with very early RA may enter remission after a short course of treatment and stay off meds for months or even years. But this is uncommon. Most people who stop treatment-even if they feel fine-will see their disease return. T2T doesn’t recommend stopping meds just because you’re in remission. The goal is to maintain it, not risk a flare.
How often should I get my DAS28 checked?
When your RA is active or you’re adjusting treatment, check every 1 to 3 months. Once you’re in stable remission or low disease activity, you can space it out to every 3 to 6 months. If your doctor is only checking you once a year, that’s not T2T. You deserve more frequent monitoring.
Are biologics the only option if methotrexate doesn’t work?
No. Many patients benefit from adding a second or even third conventional DMARD-like sulfasalazine or hydroxychloroquine-before jumping to biologics. Triple therapy (methotrexate + sulfasalazine + hydroxychloroquine) works for nearly half of patients who don’t respond to methotrexate alone. Biologics are powerful, but they’re not always the first step after methotrexate.
Why do some doctors still not use treat-to-target?
It takes time, training, and resources. Measuring joint counts, calculating scores, and adjusting meds based on data requires more than a quick visit. Many private practices are understaffed or lack electronic tools to automate scoring. Some doctors were trained before T2T became standard and haven’t updated their practice. But awareness is growing-especially in academic centers, where over 85% now use it.
What if I can’t afford biologics or JAK inhibitors?
Talk to your rheumatologist about alternatives. Some countries have patient assistance programs. Generic versions of older DMARDs are often affordable. In some cases, switching to triple therapy or using lower-cost biologics (like biosimilars) can cut costs by 30-50%. Don’t assume you can’t access treatment-ask for help. Many clinics have social workers who specialize in RA medication access.
Does treat-to-target work for everyone?
It works best for early RA-especially within the first year of symptoms. In established RA, it still improves outcomes, but remission rates are lower. The goal shifts from full remission to low disease activity. For some, especially those with long-standing damage or other health conditions, the focus becomes preserving function and quality of life, even if remission isn’t possible. T2T is flexible-it adapts to you.
Edward Batchelder
Treat-to-target isn't just a protocol-it's a revolution in how we think about chronic disease. For years, we accepted flares as inevitable, but now we have the tools to actually silence the disease. The DREAM and BeSt trials don't lie. 58% remission versus 30%? That's not incremental. That's transformative. This isn't theoretical-it's happening in clinics right now.