Controlled Joint Inflammation but Still No Remission? It's Time to Attend to Depressive Symptoms.

Abstract

Current guidelines recommend treating patients with rheumatoid arthritis (RA) by targeting remission, or if that fails, low disease activity, providing explicit directives for pharmacological interventions when arthritis remains active1. Similar recommendations are being proposed for psoriatic arthritis2. Definitions of disease activity in immune-mediated inflammatory arthritides (e.g., Simple Disease Activity Index in RA) incorporate objective [e.g., C-reactive protein (CRP) levels] and physician-derived measures of inflammation [e.g., swollen joint counts (SJC), physician’s global assessment of disease activity (PGA)] along with patient-derived ones [e.g., tender joint counts, patient’s global assessment of disease activity (PtGA)]3. Because of ever-increasing numbers and better use of effective biologic and nonbiologic antirheumatic drugs (DMARD), remission should represent a reasonable goal for every patient with chronic inflammatory arthritis. Unfortunately, control of inflammation does not directly translate into remission. Rheumatologists confidently use their PGA (and SJC) as their gold standard for treatment decisions regarding DMARD4, but remain puzzled when the inflammation is well controlled, but the patient still feels ill5. Persistent pain, fatigue, functional limitations, and psychological factors all contribute to elevated PtGA values in patients with controlled inflammation6. Ferreira, et al recently described this disconnect as 2 complementary domains needing distinct approaches: (1) control of inflammation, reflected by CRP and SJC, using DMARD; and (2) effect of disease indicated by elevated PtGA values, using adjunctive therapies yet to be defined6. There are biological, behavioral, and psychological reasons for the connection between inflammatory arthritis and affective disorders. Elevated levels of proinflammatory cytokines (e.g., interleukin 6 and tumor necrosis factor-α) limit psychological adaptation to disease, and when … Address correspondence to Dr. G. Boire, Department of Medicine, CIUSSS de l’Estrie - CHUS, 3001 12th Ave. North, Division of Rheumatology, Room 3853, Sherbrooke, Quebec J1H 5N4, Canada. E-mail: gilles.boire{at}usherbrooke.ca