Friday, 19 Jul 2019

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Remission Unlikely in RA

Dr. Marwan Bukhari (editor of Rheumatology) has written and editorial wherein he suggests that true remission is hard and rare.  He notes that "remission as a target is a noble objective that we should all aspire to but we should not chastise our practice if we do not achieve it, as more and more evidence suggests that we should consider it the ideal but not the norm."

Remission is clearly the ideal as it is associated with better outcomes, less disability, and less radiographic damage.

Despite the pervasive belief that treatment of rheumatoid arthritis (RA) should be early, and aggressive, there are practicalities that make this difficult - both in practice and in registries. 

Several factors that mitigate or muddy the chance of remission include:

  • formal disease activity measures that do not include all joints (including those below the knees)
  • true remission rates are very low in trials
  • remission rates may vary depending on the definition used for remission
  • patients and physicians often overlook residual inflammation when drug escalation would be beneficial

The editorial was writtent to address a concurrent article in the journal where in large Swedish study examined the epidemiology of remission (using different criteria) and also sustained remission (defined as remission lasting ≥6 mos.).

Remission in the Swedish study was considered in 4 ways: DAS28-ESR <2.6, clinical disease activity index (CDAI) <2.8, simplified disease activity index (SDAI) <3.3, ACR/EULAR Boolean (i.e. tender joint count ≤l and swollen joint count ≤l and CRP ≥10 mg/l and patient global assessment <1 VAS 0 to 10 scale).

Only a few factors were predictive of remission - early disease, male gender, low disability and ACPA positivity, but swollen joint counts.

Early diagnosis was associated with achieving sustained remission, as well as the absence of ACPA.

Sustained remission was twice as likely using the DAS28 criteria vs CDAI, SDAI or Boolean criteria. Whereas 41.9% achieved a DAS28 sustained remission at some time point, CDAI, SDAI and ACR remission were seen in 22.2, 21.3 and 17.5%, respectively.

Sustained remission in one year was seldom seen in 16.4, 6.5, 6.0 and 4.6% using the DAS28, CDAI, SDAI and ACR remission, respectively.

The prevalence or remission peaked after 5 years for all criteria. It took some patients up to 15 years to achieve remission.

The affirmation that treating disease early also increases the chances of remission in real life would also be a lesson for our community, and encourage us as a community to seek ways in which to reduce delays in referral to specialist care.

While remission and sustained remission are possible, it is realistic in a smaller subset of patients.

Maybe other, more achievable measures of how to achieve good disease control are needed in our efforts toward an ideal response. 

The author has no conflicts of interest to disclose related to this subject

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