Your Rheumatoid Arthritis Plan: When Remission Is the Target

For RA patients with low disease activity or early disease, remission may be an achievable goal.

aiming for RA remission hopeful
Remission, when disease activity is so minimal that you can function at your fullest, is possible.
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Getting a diagnosis of rheumatoid arthritis (RA) once meant heading for almost certain disability, but that’s not the case anymore. Treatment with newer drugs, along with positive changes in lifestyle factors, offer a much more hopeful outlook.

Being in remission from RA is now something many people can realistically strive for, experts agree.

In an article providing remission criteria jointly published by the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) in Arthritis & Rheumatology in October 2022, the groups note that “remission has become a key target for the management of patients with RA.”

The consensus criteria from the two expert groups provides guidance for rheumatologists.?This final criteria updates preliminary remission yardsticks the groups issued a decade ago.

According to the ACR, remission is an especially reasonable goal for people early in the course of the disease and for those who have had minimal exposure to biologic and targeted synthetic disease-modifying anti-rheumatic drugs, or DMARDs.

Other people might better initially aim for low disease activity as an initial target, but once that is reached, remission may be the next logical step.

“The assessment of disease activity and potential remission always needs to be put in the personal context of the patient,” says Paul Studenic, MD, PhD, a post-doc researcher at Karolinska Institutet in Stockholm, and a corresponding author of the newly published criteria.

RELATED: Experts Expand Definition of Rheumatoid Arthritis Remission

What Remission Means for People With Rheumatoid Arthritis

Remission doesn’t mean you’re cured.

It means that your symptoms (the ones you feel and the ones you don’t, such as abnormally high levels of inflammation cytokines) are almost totally alleviated or are at such a low level that you’re able to move and function at your fullest, performing common household tasks, such as dressing, cleaning, bathing, cooking, and shopping.

In addition, your joints are not being further damaged by the disease.

Why Reaching Remission Can Be Beneficial

People who achieve sustained remission can go about their lives in a state of near normality, with less pain and fatigue than those with more active disease, according to a review of research published in Therapeutic Advances in Musculoskeletal Disease?in August 2017.

In addition, the reviewers found that those who achieved remission at any point in the course of their disease had better long-term outcomes than others — regardless of whether that remission happened soon after diagnosis or many years later.

Many Factors Influence How Likely You Are to Experience RA Remission

According to Ashira Blazer, MD, a rheumatologist and an assistant professor of medicine at Weill Cornell Medical College in New York City, your chances of experiencing remission depend on a number of things, including:

  • How soon you are diagnosed after the disease begins and how quickly you begin drug treatment (the sooner you’re diagnosed and treated, the greater your chance of remission).
  • How many joints are tender and swollen when you are first diagnosed (the fewer joints involved, the greater your chance for remission).
  • Your blood levels of certain proteins that indicate whole-body inflammation, namely ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein).
  • Whether you have certain inflammatory markers associated with the disease, including?rheumatoid factor (RF), or the antibody known as anti-cyclic citrullinated protein (ACPA). People without RF or ACPA — those who have so-called seronegative rheumatoid arthritis — have a greater chance of remission.
  • Whether or not bony damage from RA can be seen on X-rays when you are first diagnosed. (The less damage present at diagnosis, the better your chance of remission.) Your physician will determine joint damage by performing periodic X-rays to look for changes in the bones closest to the joints.

Your Expectations May Also Play a Role

It may seem that a person’s response to a medication that might lead to remission is a purely physical thing, but there's evidence to the contrary.

When 100 people with RA were asked questions before they started a new DMARD and then evaluated later for physical improvements, more than 10 percent of their treatment response could be attributed to their earlier expectation that the drug would be effective, according to a study published in Therapeutic Advances in Musculoskeletal Disease in May 2021.

How Do I Know if I’m in Remission?

Rheumatologists generally follow the ACR-EULAR remission guidelines, which were finalized with the publication of the 2022 journal article. “A clinical definition of remission for RA should reflect no or only minimal disease activity, and patients attaining this state should have a low risk of both structural progression and functional impairment,” the article states.

The guidelines recommend the use of several scales that have been shown to reliably predict RA’s impact on the body.

  • A tender joint count (TJC) and swollen joint count (SJC)
  • A measure of function as is done with a Health Assessment Questionnaire (HAQ)
  • An acute-phase reactant such as C-reactive protein (CRP) level
  • An evaluator-physician global assessment (EGA)
  • And a patient assessment of global disease activity and pain, known as PtGA.

In the earlier draft guidance, the PtGA score was required to be less than 1 centimeter (cm), on a scale of 1 to 10 cm.

However, after careful analysis, the ACR and EULAR decided to change the desired PtGA score to less than 2 cm.

This change was made based on data from several clinical trials that were not evaluated before the initial draft was recommended, Dr. Studenic says. This change allows patients who missed the prior cutoff but were otherwise tremendously improved to now be considered in remission, he says.

“We have shown that the performance in terms of long-term outcomes remained similar and prevent to the largest amount radiographic damage and retain good functional ability,” he says.

Some Criticism Exists for These Disease Markers

Not every rheumatologist embraces the ACR-EULAR criteria for remission.

As researchers noted in a letter to the British Medical Journal published in May 2017, there are several shortcomings to this approach: Joints in the feet are not included in the count. And imaging like ultrasound or MRI are not used to confirm whether even low levels of joint inflammation remain.

In fact, a review study published in the Journal of Inflammation Research in June 2021 found that subclinical joint inflammation may be detectable by imaging in people who seem to be in remission from a clinical standpoint, leading to questions about “whether it is appropriate only to use clinical composite scores as treatment target in clinical practice,” the authors stated.

Other scales sometimes used include the Clinical Disease Activity Index (CDAI), the Simplified Disease Activity Index (SDAI), and the Routine Assessment of Patient Index Data 3 (RAPID3).

The Treat-to-Target Strategy for RA Treatment

A key reason that experts want to define remission and low disease activity using specific and strict criteria is to help physicians treat patients to achieve remission as part of the practice known as “treating to target."

This approach is where a doctor and patient agree up front on what the treatment goal is, then regularly test to see if that goal is being met, and adjust medicines accordingly if it has not. It has resulted in a higher rate of remission, as well as improved mobility over time and less damage to the joints.

In research published in January 2018 in the journal Arthritis & Rheumatology, treating to target was shown not only to increase the remission and low-disease-activity rates, but also to improve cardiovascular disease risk factors including HDL “good” cholesterol level and function.

When remission criteria were first discussed by the rheumatology groups in the 1990s, remission "was more aspirational than a realistic goal,” the 2022?Arthritis and Research?journal article states. “Today, however, remission can be obtained in a sizable portion of patients and is seen as a major therapeutic target.”

Medication Is Key to Achieving Remission

The most important factor in rheumatoid arthritis remission is early and aggressive treatment with medication that improves or alleviates symptoms and halts the progression of the disease, experts say.

Because RA is a systemic inflammatory disease, it can affect all body systems, not just joints. When untreated or undertreated, RA puts patients at higher risk for developing coronary artery disease, stroke, and other cardiovascular disease compared with those whose disease is in remission. While even well-treated people with RA have higher cardiovascular risk both because of the disease and medication side effects, tight RA control substantially improves CV risk, experts say.

That’s because effective treatment reduces chronic inflammation and reduces the need for high doses of steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), Dr. Blazer says, noting that both of these can raise cardiovascular risk.

Although RA drugs do have side effects, the repercussions of the disease, including permanent joint damage, are generally much worse than the side effects associated with the medications.

Stopping RA Disease Progression With Drugs

Because rheumatoid arthritis is a disease of an overactive immune system, many drugs used to treat it suppress the immune system. The disease-modifying antirheumatic drug (DMARDs) methotrexate (Trexall) should be the first drugs doctors use, according to the most recent?ACR treatment guidelines (PDF)?released in 2021. This drug improves pain and inflammation and also helps slow the progression of arthritis.

If methotrexate is not sufficient, after a time doctors should consider adding a biologic. These are genetically engineered drugs that block cytokines, the body’s inflammatory chemicals (such as interleukins and tumor necrosis factor).

Increase Your Odds of Staying in Remission

Once you achieve remission, it’s important to stay vigilant in order to prevent a relapse. Of those who achieve remission, about half will relapse with a flare within six months, according to Blazer.

Why Does Remission End and Relapse Occur?

The No. 1 reason people with RA relapse? They go off their medications.

People start feeling good and stop their meds, but doing so is rarely beneficial. “It may be tempting to stop the medications once you start feeling better, but the immune system has a great memory. This is a good thing when it comes to creating antibodies for infections. But in the case of autoimmune disease, our immune system’s memory is problematic,” explains Blazer.

“Once the immune system finds a target, such as your joints in RA, it will continue to pursue that target unless it is signaled to stop. The medications provide that ‘stop’ signal, and discontinuing them can cause a flare-up to ensue,” she says.

The ACR treatment guidelines call for people to remain on their medicines even after symptoms abate. At a minimum, it notes, one DMARD should always be continued. People who want to work with their doctor to taper their dose should do so only after they have been in remission or have low disease activity for at least six months.

What Else Helps People Achieve or Maintain Remission?

In addition to staying on medications and being checked regularly by a rheumatologist, the following lifestyle factors can help prevent a relapse:

Regular Exercise Aerobic and weight-bearing exercise strengthens muscles and takes the pressure off painful joints, which may be stiff and fatigued, in part because of reduced motion. Although people with RA may feel like they are in too much pain to exercise, movement is key to nipping chronic pain in the bud.

Adequate Sleep Sleep supports the immune system. Anyone with an inflammatory disease like RA needs at least seven hours of sleep.

Mediterranean-Style Diet A study published in the journal Annals of Rheumatic Diseases (PDF) found that after two years on a Mediterranean diet (lots of fresh fruit, olive oil, fish, legumes, wine, and a decrease in red meat and animal fats), people with RA experienced a decrease in inflammatory markers, an increase in function, and felt more energized compared with those eating a Western diet.

Weight Management People with RA who have higher body mass index (BMI) scores were found to have lower rates of remission and higher rates of disability, according to?research presented at the 2017 ACR annual conference.

Stress Management There is a huge connection between our minds and bodies, and stress can trigger autoimmune conditions like RA because it can cause the body to secrete inflammatory chemicals. Stress, and the?catastrophizing that often accompanies it, can make RA feel more painful.

Proven ways to reduce the stress response include regular meditation, deep breathing, being in nature, taking a mindfulness-based stress reduction (MBSR) course, and working with a counselor to learn stress-management techniques.

Quitting Smoking Of those who smoke, only a small percentage will experience remission, in part because smoking blunts the effects of RA drugs, says Jonathan Greer, MD, a rheumatologist in Boynton Beach, Florida.

Ask your doctor for a referral to a smoking cessation expert or to help you quit with the help of proven techniques such as the nicotine patch, nicotine gum, counseling, and drugs such as Chantix (varenicline).