Decreasing disease activity in people with rheumatoid arthritis (RA) has long been the goal of medical treatment. But measuring when a person has met their goal — when symptoms are alleviated or at a low enough level that they don't impair function or overall health — is not always clear.
For more than a decade, rheumatologists have debated the criteria for how to know when a person is in remission from RA.
Now the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) have released final guidance for rheumatologists on their criteria for remission.
The new criteria, published in Arthritis & Rheumatology on October 23, 2022, revise preliminary guidance the groups issued a decade ago.
The revised guidance is “based on trial data not used [previously] for deriving or assessing the relevance of the remission criteria,” says Paul Studenic, MD, PhD, a post-doc researcher at Karolinska Institutet in Stockholm, and a corresponding author of the newly published criteria.
Defining Remission for Rheumatoid Arthritis
In rheumatology, remission does not mean a person is cured. They still have rheumatoid arthritis.
But remission is desirable. It's when symptoms and laboratory levels, such as measures of inflammatory cytokines, are extremely low and the disease no longer interferes with the ability to function well.
While RA is a progressive disease, people who are in remission also generally don’t experience further joint damage from the disease.
Earlier Efforts to Establish Criteria for RA Remission
In 2011, the ACR and EULAR agreed on provisional criteria for remission in rheumatoid arthritis.
These criteria included four components:
- A tender joint count (TJC) and swollen joint count (SJC)
- A measure of function such as the Health Assessment Questionnaire (HAQ)
- An acute-phase reactant such as C-reactive protein (CRP) level
- The patient assessment of global disease activity, known as PtGA, and the evaluator/physician global assessment (EGA).
To be considered in remission, the PtGA score was originally required to be less than 1 cm, which is a scale of 1 to 10.
Loosening Criteria Puts More Patients in the Clinical Remission Category
Over the years, it became clear that some patients reached remission levels for three of the categories but not for the category of patient assessment of global disease activity.
As the researchers noted in the Arthritis & Rheumatology article, experts have long debated the importance of keeping the strict criteria for this category. In some cases, for example, patients with pain from irreversible joint damage would not rate their PtGA extremely low even if by all other measures their RA was in clinical remission.
Some patients just barely missed the classification of being in remission solely due to a slightly elevated PtGA, Dr. Studenic says.
New Criteria Makes Remission a More Reasonable, Reachable Goal
In determining whether they could change this criteria without altering disease progress, the ACR and EULAR looked at four clinical trials that compared biologic drugs to methotrexate alone or to a placebo.
After analyzing the data, the groups found that accepting a patient's global assessments of disease activity score of 2.0 cm rather than limiting it to 1.0 still predicted good physical function later on and kept the disease from progressing, as measured by radiography.
By using this more-expansive criteria, the proportion of patients with disease in remission six months after their initial treatment increased from 14.8 percent to 20.6 percent in people with early RA, and from 4.2 percent to 6 percent in those with more established disease.
This finding led the groups to endorse the prior provisional criteria with the change of the new level for PtGA, as they noted in the journal article.
“We have shown that the performance in terms of long-term outcomes remained similar and prevent to the largest amount radiographic damage, and people retain good functional ability,” Studenic says.
Remission Criteria Set the Targets for RA Treatment
Coming to an agreement on the definition of remission is more than an academic exercise.
Rheumatologists are urged to work with patients to agree up front about treatment goals, an approach known as “treating to target.” Having an agreed-upon, validated measure of that target helps with this process.
These new, validated remission criteria “allow practitioners to have a new goal that is attainable for their RA patients,” says Vinicius Domingues, MD, a rheumatologist in Daytona Beach, Florida, and a medical adviser to the online arthritis support group CreakyJoints, who was not involved in setting the criteria.
After one or more medicines are given, a person is regularly tested to see if the agreed-upon goal is closer to being met. If not, medications are adjusted or changed.
“In the end, communication and shared decision-making that results in the best quality of life now and in the long run is essential,” Studenic says.
Early Medication Is the Best Path to Achieving Remission
Rheumatologists agree that early and aggressive treatment with disease-modifying antirheumatic drugs (DMARDs), including biologics, is the best way to ultimately achieve remission.
Untreated or undertreated RA not only can damage joints, it increases the likelihood that people will develop other conditions, including coronary artery disease and stroke, compared with those whose disease is in remission.