Combining treat-to-target principles with patient choice: A small step AHEAD in the right direction

The treat-to-target approach specifies optimum treatment targets such as blood glucose levels that result in health benefit. Setting single targets for complex inflammatory conditions such as atopic dermatitis (AD) is challenging, and depends on which disease aspects disease are considered to be important, by whom, along with how and when to measure them. A criticism of treat-to-target is its one-size-fits-all approach. Patients/carers may have different preferences on what is important for them, and what is a worthwhile gain when traded-off against the harms and inconvenience of particular treatments.

To address these limitations of a treat-to-target approach, the AHEAD (Aiming High in Eczema/Atopic Dermatitis) international group sought to identify what aspects of atopic dermatitis (AD) might be included in a treat-to-target approach and how they might be measured.¹ The group's previous survey identified the most significant symptoms for adult AD patients, how they are measured and treatment expectations. The group used that data to draft a series of treatment recommendations that were subject to a Delphi survey involving 77 AD experts. Unusually, consensus was reached for all 34 recommendations after just one voting round. The group suggest that patients should identify between one to three from six features selected by the AD experts (itch, skin appearance, sleep disturbance, mental health, skin pain and daily life impact). The clinician also chooses an additional objective assessment of disease control. Targets for both optimal and moderate control are suggested for these outcomes for 3–6 months, and monitored with a recommended instrument chosen by the clinician.

What I liked about this initiative was the attempt to combine the best of both worlds—retaining more ambitious treatment targets for people with AD with some input from patients on what to measure and how. The proposed outcomes align with clinical practice outcomes from the Harmonising Outcomes Measures for Eczema (HOME) initiative.² I also liked the flexibility for moderate as well as optimal control.

What was missing was lack of consideration of other crucial aspects that govern treatment choices for patients including adverse effects, inconvenience, access and costs. Although adverse effects may be treatment-specific, balancing benefits and harms is a mandatory part of shared decision-making as exemplified in AD patient decision aids.³ The preceding adult patient qualitative work, sponsored by AbbVie and cited only in abstract form, was useful but limited, as young people and children/carers where AD is commonest were not included. Although the adult qualitative study was considered when drafting the initial AHEAD recommendations, the complete absence of patient/carer involvement in the final recommendations was disappointing. Other initiatives such as HOME have found that working with patients/carers at consensus meetings fulfilling, even for complex issues such as disease measurement scales.

Lack of consensus often drives the need for consensus.⁴ The fact that consensus was achieved in just one round sounds fortuitous, but it came across like group think. There was little evidence of learning from dissenting voices, and the bar for defining agreement that included ‘mildly agree’ was quite low. The definition of treatment ‘success’ is also not clear given that patients can nominate up to three targets. Similarly, if a patient looks better according to >75% EASI reduction but deteriorates on their nominated symptom score, is that a ‘success’ or a case of looking better but feeling worse?⁵ Frequency of outcome assessment is not mentioned. The list of conflicts of interest of the group is impressive and runs into two pages. Whether such heavy ties with an industry that develops new systemic treatments have influenced the initiative is unclear.

AHEAD represent a step forward in combining ambitious treatment targets, patient choice and reliable outcomes. The next step is genuine rather than partial involvement of patients and carers of all ages and the creation of decision aids that that trade-off ambitious treatment targets with potential harms.

The author is a member of the executive of the Harmonising Outcome Measures for Eczema (HOME) initiative that has proposed core outcomes for atopic dermatitis research and clinical practice cited in this article. He has no conflicts with the pharmaceutical industry.