Rheumatism Remission Criteria Research Articles

Validity of Remission Criteria in Rheumatoid Arthritis Compared to Ultrasound-Defined Remission.

Remission is the ultimate purpose of treatment in rheumatoid arthritis (RA). However, even when the most stringent composite scores are used, structural damages can occur; hence, ultrasonography (US) appears to be the best way to assess real remission. This study aimed to investigate the validity of different RA remission scores using US as a reference. An analytic diagnostic study, of 30 RA patients in remission (according to the Disease Activity Score in 28 Joints [DAS28]) and a control group with active RA, was conducted between January and October 2018 at Mongi Slim Hospital in Tunis, Tunisia. Among them, patients in remission were identified according to their Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and the Boolean American College of Rheumatology/European League against Rheumatism activity index (ACR/EULAR) remission scores. The validity of each activity score for remission was calculated by considering the absence of power Doppler (PD) signals as a gold standard. All patients were in remission according to the DAS28, with an average score of 2.03 (1.1-2.6). US examination showed PD signals in 57% of patients. A total of 26 patients were in remission according to the CDAI; a Doppler signal was detected in 58% of those cases. SDAI remission was accomplished in 19 patients, with PD activity in 53% of cases. Of the 14 patients in remission according to the Boolean ACR/EULAR criteria, synovial hyper-vascularisation was found in 64%. Considering true remission as the absence of PD signals, the most sensitive and specific score was the DAS28 (93% and 68%, respectively). Considering remission in RA as the absence of vascularised synovitis, the DAS28 is the most sensitive and most specific score.

Considerations and priorities for incorporating the patient perspective on remission in rheumatoid arthritis: An OMERACT 2020 special interest group report

ObjectiveTo determine how best to incorporate the patient perspective into rheumatoid arthritis remission criteria. MethodsAt OMERACT 2020, several studies, including a longitudinal multi-centre study testing the validity of adding patient-valued domains to the ACR/EULAR criteria, were presented and discussed by the virtual Special Interest Group. ResultsOverall consensus was that there is insufficient evidence to change the remission criteria at this point. Future work should focus on measurement of the new domain of independence, clarifying the value of the patient global assessment, and optimizing the input of domains that patients value in the criteria. ConclusionIncorporating the patient perspective into remission criteria should be further explored.

Comparable long-term outcomes between DAS28-ESR remission criteria and ACR/EULAR definitions in patients with established rheumatoid arthritis.

To compare long-term clinical, immunological, and radiographic outcomes between five sets of remission criteria (four clinical and one ultrasound (US)-based) in a cohort of RA patients in a clinical care setting. RA patients in remission (DAS28-ESR <2.6) were selected. HandUS assessments were made, and serum levels of inflammation/angiogenesis biomarkers were determined at baseline. Changes in baseline treatment and radiographic progression, defined as the variation in the modified Sharp van der Heijde score (mSHS) at 5 years, were analyzed. Five concepts were used to define remission: DAS28-ESR<2.6, SDAI<3.3, CDAI<2.8, Boolean criteria and Power Doppler score (PD)=0. Eighty-seven patients with DAS28-ESR<2.6 were included. One-third fulfilled SDAI (33.3%), CDAI (31%), and Boolean (35.6%) remission criteria, and 25.3% had no PD signal in the US evaluation. 26 patients (29.9%) changed therapy, ranging from 13.6% (PD remission) to 33.3% (CDAI remission) (p=0.11). Serum levels of ANG (p=0.015) and TNFa (p=0.025) were significantly lower in patients with Boolean remission, whereas IL-18 levels were significantly lower in those with PD remission (p=0.049). Patients without PD in the US assessment had significantly-lower mSHS erosion progression (p=0.014) at 5 years. Patients with established RA in DAS28-ESR remission had comparable clinical and radiographic outcomes in SDAI, CDAI, and Boolean definitions in a clinical care setting. US remission remained the closest to structural damage abrogation. Key Points • This study provides real world data on long-term outcomes of five clinical and imaging remission criteria in rheumatoid arthritis. • DAS28-ESR remission criteria had comparable radiographic progression and clinical prognosis than more stringent criteria in clinical practice. • US-based remission was closest to structural damage abolishment.

Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients

ObjectivesTo determine the impact of excluding patient global assessment (PGA) from the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission criteria, on prediction of radiographic and functional...

Association of age with the non-achievement of clinical and functional remission in rheumatoid arthritis

Patient-reported outcome (PRO) is included in the remission criteria of rheumatoid arthritis (RA). We aimed to determine the effect of age on PRO and the subsequent achievement of clinical and functional RA remission criteria. Three hundred and one patients with non-rheumatic diseases were evaluated using the 0–10 cm visual analog scale (VAS) assessment for musculoskeletal symptoms and a functional health assessment questionnaire-disability index (HAQ-DI). These assessments were compared with those obtained from 149 patients with RA with negative tender/swollen joint counts and normal serum C-reactive levels (objective clinical remission). Of the 301 patients, 32.2%, 26.6%, and 41.2% were classified as non-elderly (< 65 years), early elderly (65–74 years), and late-elderly (≥ 75 years) patients, respectively. VAS > 1 cm and HAQ-DI ≥ 0.5 were observed in 7.3% and 14.5%, respectively, in late-elderly patients, whereas ≤ 1.0% of non-elderly and early elderly patients for the both. Among 149 RA patients in objective remission, however, > 20% and > 10% of early elderly patients (and even non-elderly patients) had VAS > 1 cm and HAQ-DI ≥ 0.5, respectively, and 34.0% and 35.8% of late-elderly patients with RA had VAS > 1 cm and HAQ-DI ≥ 0.5, respectively. Multivariate logistic analysis revealed that age and RA were associated with the non-achievement of VAS ≤ 1 cm and HAQ-DI < 0.5. Therefore, the effect of age, which was independent of the presence of RA even without any objective disease activity, on PRO and the non-achievement of clinical and functional remission criteria was demonstrated.

Phrasing of the patient global assessment in the rheumatoid arthritis ACR/EULAR remission criteria: an analysis of 967 patients from two databases of early and established rheumatoid arthritis patients.

The ACR/EULAR Boolean remission criteria for rheumatoid arthritis (RA) include a strict cutoff for patient global assessment (PGA, value ≤ 1/10). Near-remission corresponds to remission for joint counts and C-reactive protein but with PGA > 1. The objective was to explore whether the contribution of PGA to remission and near-remission varied according to the wording of the PGA and in relation to disease duration. In patients with early arthritis (N = 731, French ESPOIR cohort) or established RA (N = 236 patients from across Europe), frequency of remission versus near-remission was assessed according to the phrasing used for PGA (global health versus disease activity). In 967 patients (mean [standard deviation] age 49.7 [12.7] years, 76.7% women), remission was infrequent: range 12.9-16.7% (according to wording of PGA) in early RA and 6.8-7.2% in established RA. Near-remission was more frequent: 13.0-16.8% in early RA and 13.1-13.6% in established RA. The ratio of remission to near-remission was higher in the early arthritis cohort (0.8-1.3 versus 0.5-0.5 in established RA). Using the disease activity PGA led to more remission and less near-remission than the global health PGA in the early arthritis cohort (12.9 vs 16.7% near-remission, respectively, p = 0.047) but not in established RA. The proportion of patients who can be classified as remission or near-remission differs in early RA compared to establish RA and depends upon the formulation of the PGA question. PGA referring to disease activity and not global health may be preferred in early disease, if the objective is more alignment with inflammation assessment.

Residual disease activity in rheumatoid arthritis patients treated with subcutaneous biologic drugs that achieved remission or low disease activity: a longitudinal observational study.

The aim of this study was to evaluate the residual disease activity (RDA) and function in rheumatoid arthritis (RA) patients treated with subcutaneous biologic drugs that achieved a status of remission and low disease activity (LDA) according to the various indices validated for RA and to explore the factors associated with RDA. We consecutively enrolled RA patients that started a new subcutaneous biologic treatment. At baseline and after 3 and 6months of treatment, we assessed the rate of patients that achieved remission or LDA using the Disease Activity Score on 28 joints, Clinical Disease Activity Index, Simplified Disease Activity Index, and American College of Rheumatology/European League Against Rheumatism remission criteria. The presence of RDA was evaluated as the rate of patients with at least tender joint count > 1, swollen joint count > 1, pain on VAS > 10mm, general health (VAS) > 10, patient's disease activity (VAS) > 10, physician disease activity (VAS) > 10, and C reactive protein > 1mg/dl. We also evaluated the impaired function defined as HAQ score > 0.5. Factors associated to RDA were also investigated. Ninety-three adult patients with RA were enrolled. At 6months, RDA occurred mostly at the level of Patient's reported outcome items and less frequently in tender and swollen joints and acute-phase reactants. Interestingly, about one fourth of patients in LDA and up to one fifth of patients in remission had residual functional impairment with an HAQ score greater than 0.5. RDA in RA was present even in patients with remission or LDA, especially for the patient's reported outcome. Impaired function was also present in a significantly rate of patients.

A reduced 12-joint ultrasound examination predicts lack of X-ray progression better than clinical remission criteria in patients with rheumatoid arthritis.

To study the predictive value of clinical remission definitions and ultrasound (US) examination on X-ray progression in rheumatoid arthritis (RA). This was an observational prospective multicenter 1-year follow-up cohort of RA patients with moderate disease activity (3.2<DAS28≤5.1) who started anti-TNF therapy. DAS28ESR, DAS28CRP, SDAI, CDAI, and ACR/EULAR remission criteria were applied and reduced 12-joint US examination was performed at baseline and at 6 and 12months. At baseline and month 12, radiographs of hands and feet were obtained in a subset of patients. A blind independent reader scored radiographs. X-ray progression was defined as Sharp van der Heijde change score>1 and no progression was defined as≤0. 319 of 357 patients completed the study; patients had a mean (SD) age of 53.5 (13.1) years, with a disease duration of 7.5 (7.1) years. Laboratory, clinical, and US values significantly improved at month 6, except CRP, with additional improvement at month 12. Remission and low disease activity rates increased at follow-up. In the subset of 115 patients with radiological studies, clinical remission by any definition was not significantly associated with X-ray progression. Patients without PD signal at baseline and month 6 were a lower risk of X-ray progression than patients with PD signal, OR 0.197 (95% CI 0.046-0.861) and 0.134 (95% CI 0.047-0.378), respectively. Absence of PD signal, but not clinical remission predicts lack of X-ray progression. A feasible 12-joint US examination may add relevant information to RA remission criteria.

Serum interleukin-6 levels in response to biologic treatment in patients with psoriasis

Objectives: Psoriasis is a chronic autoimmune disease involving a complex network of cytokines such as interleukin (IL)-6. We tested the hypothesis that serum IL-6 level is a useful indicator of disease activity and predicts the treatment response to biologics in patients with psoriasis.Methods: We analyzed 113 psoriasis patients treated with biologics (73 with infliximab [IFX], 24 with adalimumab [ADA], and 16 with ustekinumab [UST]) in our hospital. Disease severity was assessed using the Psoriasis Area and Severity Index (PASI) score, and Disease Activity Score 28 based on C-reactive protein (DAS28-CRP).Results: Before treatment, serum IL-6 levels significantly correlated with PASI scores in patients with psoriasis vulgaris (r = 0.432, p = 0.001) and with DAS28-CRP in patients with psoriatic arthritis (r = 0.469, p = 0.010). Serum IL-6 levels were significantly decreased by IFX (from 4.8 to 1.5) and ADA (from 2.5 to 1.4) therapy. In psoriatic arthritis, serum IL-6 levels at the endpoint tended to be lower in patients who achieved DAS28-CRP <2.3 (European League Against Rheumatism remission criteria) than in patients who did not.Conclusion: Serum IL-6 level may be a useful biomarker for assessing disease activity in patients with psoriasis and for predicting responsiveness of joint symptoms to biologic treatment.

Signs of forefeet joint synovitis have a limited impact on patient's perception of rheumatoid arthritis disease activity and acute-phase reactants

Objectives. To determine the prevalence and distribution of signs of synovitis in the residual joints in remission defined by the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) remission criteria and the role of their components in preventing misclassification due to reduced joint count.Methods. The cross-sectional observational data of RA patients including full joint counts were analyzed. Definitions of remission used were the ACR/EULAR RA remission criteria and their modifications using full joint counts with the same thresholds of the items and the calculated results.Results. A total of 304 RA patients with 3,149 observations could be analyzed. Patients in remission according to the ACR/EULAR remission criteria can still show residual disease activity in the feet in up to 27% of the population with a 28-joint count remission. Residual disease activity has no impact on patient's global assessment for current disease activity, when signs of concomitant ankle joint synovitis were absent.Conclusions. RA patients in remission according to the ACR/EULAR definitions can still show signs of synovitis mostly in the forefeet joints. Acute-phase reactants and patient's global assessment for current disease activity have little impact in mitigating the limitation of reduced joint count.

The MRI Features in Patients with Rheumatoid Arthritis Treated with Tocilizumab, in Clinical Remission or Low Disease Activity State

Background: Subclinical inflammation and radiographic progression have been described in rheumatoid arthritis (RA) patients whose disease are in remission or are showing a low level of activity. The aim of this study was to evaluate in patients with rheumatoid arthritis RA in clinical remission or low disease activity (LDA) using composites scores, the synovitis and the bone oedema using MRI by OMERACT RAMRIS score (RAMRIS bone oedema and synovitis RAMRIS). Methods: In this longitudinal study, were included patients with rheumatoid arthritis according to the American College of Rheumatology ACR 2010 criteria with inadequate response or intolerance to conventional synthetic DMARD, treated with Tocilizumab (TCZ). Sociodemographic characteristics, clinical and laboratory for the disease were collected at baseline (M0) and 06 months (M6) of treatment. Clinical remission was defined by a DAS 28- ESR<2.6, a CDAI<2.8, a SDAI<3.3 and by ACR EULAR criteria. All patients underwent MRI of the dominant hand and wrist. MRI features were evaluated according to the Outcome Measure Clinical Trial in Rheumatoid Arthritis Rheumatoid Arthritis MRI Scoring system (OMERACT RAMRIS synovitis and bone oedema). Results: 22 patients with RA were included, 19 females (86.4%), with a mean of age 42 ± 13.7 years. The mean disease duration was 8 ± 5.2 years. The mean DAS 28 was 5.8 ± 0.94. Three patients were excluded from the study for serious side effects. At 06 months, the median SDAI was 18 (10-27).The median CDAI was 10 (5-20).The mean RAMRIS score was 2.23 ± 6.33 for bone oedema, 4.76 ± 4.02 for synovitis and 43.32 ± 30 for erosion. Using DAS28ESR as criteria of remission, it did not exist significant differences between the 3 groups of patients (remission/LDA/active disease) for the presence of synovitis on MRI (p=0.43). There was also no difference between the three groups for the presence of bone oedema (p=0.08). Moreover, defining remission by SDAI, CDAI or ACR EULAR criteria, the RAMRIS synovitis and bone oedema RAMRIS did not differ by the level of disease activity. Conclusion: This study suggests that patient in clinical remission or LDA evaluated by composites scores showed inflammation (synovitis and bone oedema) on MRI. Thus clinical remission would be different from the imaging remission. MRI and ultrasound are currently one of the criteria for remission in RA, further studies are needed in particular to determine the threshold definition of remission on MRI.

THU0451 The Formulation of the Patient Global Assessment Question Influences the Classification of Patients with Rheumatoid Arthritis (RA) into Acr/Eular Remission: an Analysis of Patients Enrolled in ESPOIR and Comedra

BackgroundThe recently developed ACR/EULAR Boolean remission criteria for rheumatoid arthritis (RA) include not only remission for joint accounts and CRP, but also for patient global assessment (assessed by a patient...

Remission criteria and activity indices in psoriatic arthritis.

Remission criteria and activity indices used in rheumatoid arthritis (RA) are often applied in psoriatic arthritis (PsA). Some new indices have been specifically developed for PsA. Our objective was to evaluate the performance of different remission criteria and activity indices in PsA. This is a cross-sectional study that includes consecutive patients with PsA. Information necessary to complete the following indices was captured: Composite Psoriatic Disease Activity Index (CPDAI), Psoriatic Arthritis Screening and Evaluation (PASE), Disease Activity Index for Psoriatic Arthritis (DAPSA), Disease Activity Score in 28 Joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) Boolean RA remission criteria. Patients were classified according to activity categories (remission, low, medium, or high disease activity). Correlation between indices was established. Fifty-five patients were included. Mean age was 53 years (SD = 12), and 35 (63.6 %) were males. Mean PsA disease duration was 5.9 years (SD = 8.5), and mean psoriasis duration was 15.9 (SD = 12.6). We found important differences in the percentage of patients classified as in remission by applying different remission criteria: DAS28 = 33 % (95 % confidence interval (CI) 20-45) vs ACR/EULAR = 4 % (95 % CI 1-17). Particularly, DAS28 and minimal disease activity seemed to be less stringent in PsA than the other indices. Of the specific PsA indices evaluated, CPDAI showed the poorest correlation with all the other activity measurements, although differences were not statistically significant in most cases. Disease activity in PsA is measured by many different indices. In spite they all showed good correlations between them, they classified different patients in different disease status.

Discordance and accordance between patient’s and physician’s assessments in rheumatoid arthritis

Objectives: The American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria for rheumatoid arthritis (RA) are more stringent than index-based criteria, making it more difficult to achieve a patient’s global assessment (PGA) than an evaluator’s global assessment (EGA). We investigated the reason for the discrepancy between the PGA and the EGA in a Japanese clinical cohort.Method: We assessed clinical and laboratory variables in our clinical cohort. The frequency of remission achievement according to the ACR/EULAR remission criteria and predictors of the discrepancy between the PGA and EGA were analysed.Results: Of 370 patients with RA, 89 fulfilled PGA criteria and 167 patients fulfilled EGA criteria. The PGA was highly correlated with the visual analogue scale (VAS) pain score and non-inflammatory variables including Steinbrocker class and the Health Assessment Questionnaire Disability Index (HAQ-DI). Conversely, inflammatory variables, including swollen joint count (SJC), tender joint count (TJC), and C-reactive protein (CRP) levels, were significantly associated with the EGA. The main predictors of the discrepancy between the PGA and the EGA were patient’s VAS pain score, SJC, and functional disability.Conclusions: Increased pain and functional disability led to a discrepancy towards a worse PGA than EGA, whereas increased SJC led to an accordance towards a worse EGA.

Remission Thresholds in Spondyloarthritis: A Prospective Study in Current Practice

To the Editor: Remission is the current target of management of chronic rheumatic diseases1,2. Whereas in rheumatoid arthritis remission criteria have been proposed3, in spondyloarthritis (SpA), no activity score allows a specific definition for remission. SpA activity is evaluated with the BASDAI score (Bath Ankylosing Spondylitis Disease Activity Index) and more recently with the ASDAS (Ankylosing Spondylitis Disease Activity Score), taking into account C-reactive protein (CRP), and validated by the ASAS group (Assessment in Ankylosing Spondylitis International Society)4. Thresholds for the ASDAS score have been proposed to classify disease activity (inactive, moderate, active, very active)5,6, and ASAS proposed … Address correspondence to Prof. D. Wendling, Department of Rheumatology, CHRU, University Teaching Hospital, and Universite de Franche-Comte, Boulevard Fleming, F-25030 Besancon, France. E-mail: dwendling{at}chu-besancon.fr

American College of Rheumatology/European League Against Rheumatism Remission Criteria for Rheumatoid Arthritis Maintain Reliable Performance When Evaluated in 44 Joints

To investigate the performance of the new remission criteria for rheumatoid arthritis (RA) in daily clinical practice and the effect of possible misclassification of remission when 44 joints are assessed. Disease activity and remission rate were calculated according to the Disease Activity Score (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and a Boolean-based definition for 1402 patients with RA in Keio University Hospital. Characteristics of patients in remission were investigated, and the number of misclassified patients was determined--those classified as being in remission based on 28-joint count but as nonremission based on a 44-joint count for each definition criterion. Of all patients analyzed, 46.6%, 45.9%, 41.0%, and 31.5% were classified as in remission in the DAS28, SDAI, CDAI, and Boolean definitions, respectively. Patients classified into remission based only on the DAS28 showed relatively low erythrocyte sedimentation rates but greater swollen joint counts than those classified into remission based on the other definitions. In patients classified into remission based only on the Boolean criteria, the mean physician global assessment was greater than the mean patient global assessment. Although 119 patients had ≤ 1 involved joint in the 28-joint count but > 1 in the 44-joint count, only 34 of these 119 (2.4% of all subjects) were found to have been misclassified into remission. In practice, about half of patients with RA can achieve clinical remission within the DAS28, SDAI, and CDAI; and one-third according to the Boolean-based definition. Patients classified in remission based on a 28-joint count may have pain and swelling in the feet, but misclassification of remission was relatively rare and was seen in only 2.4% of patients under a Boolean definition. The 28-joint count can be sufficient for assessing clinical remission based on the new remission criteria.

AB0462 The performance of new EULAR/ACR RA remission criteria in patients treated with biologic agents: Real-life experience

Backgroundnew EULAR/ACR rheumatoid arthritis (RA) criteria for the definition of clinical remission have recently been proposed and their effectiveness is still on debate.Objectivesto examine the performance of new EULAR/ACR RA...

AB0347 Validation of the clinical remission criteria in rheumatoid arthritis at keio immunotherapy center

BackgroundRemission has become the realistic goal in rheumatoid arthritis (RA) with the advent of new therapy including biologic agents. In 2011 ACR/EULAR has developed new definition of remission in RA...

AB0265 RADAI-5 remission represents 2011 ACR/EULAR proposal for remission with high specificity

BackgroundNew remission criteria for Rheumatoid Arthritis (RA) were recently proposed by ACR and EULAR (1). It was of interest if a patient centred disease activity score as the Rheumatoid Arthritis...

AB0267 Does the change of questions assessing patient’s global assessment influence composite scores in rheumatoid arthritis? is there also an influence on agreement of the composite scores to a patient outcome measure like the RADAI-5?

Background2011 the ACR and EULAR proposed new remission criteria for Rheumatoid arthritis (RA) [1]. According to this publication from now on wording of the question about patient’s global assessment should...