Treat-to-target reshaped rheumatoid arthritis, lupus and spondyloarthritis by doing three unglamorous things: defining the goal in advance, measuring the same domains every visit, and changing treatment when the target is not met. Adult idiopathic inflammatory myopathies have never had that framework, and the cost shows as persistent low-grade activity, accumulated steroid toxicity and irreversible organ damage that arrived while everyone was waiting to see.
This expert perspective in Arthritis and Rheumatology makes the case and, unusually, leads with why it is hard. There is no validated definition of remission or of low disease activity in myositis. Existing activity measures have known limitations. The disease presents across muscle, skin, lung, joints and gut in combinations that do not move together. And distinguishing active inflammation from established damage — the question that decides whether escalating helps — is genuinely difficult. The framework proposed is domain-based rather than score-based: muscle, skin, pulmonary and patient-reported outcomes assessed separately, targets individualised to phenotype and accumulated damage, biomarkers interpreted with their limits in mind, and shared decision-making built in.
This is opinion, not evidence, and it should be read as a way of organising a clinic rather than as a guideline. But the operational half costs nothing and can start at the next visit: agree an explicit target with the patient, write down which domains you will follow and how you will measure them, set the interval at which you will judge it, and say in advance what failing the target will trigger. Most of the benefit that treat-to-target delivered in rheumatoid arthritis came from that discipline rather than from any particular threshold — and it is the half of the method that does not need a validated definition to begin.
- Agree an explicit target with the patient and record it, rather than reviewing against impression.
- Follow muscle, skin, lung and patient-reported domains separately; they move independently.
- Set the review interval and the escalation trigger in advance, at the same visit.
- Check lung function and a patient-reported measure on schedule, not only when the patient complains.
- Plan the glucocorticoid taper as an explicit target of its own, with a date.
Why it matters
Myositis reviews are mostly conducted against impression, and damage accrues quietly while treatment is unchanged.
Don't overread it
This is an expert perspective, not a validated framework — no trial has shown that treat-to-target improves outcomes in myositis.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for rheumatology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free