Do Remission Criteria for RA Reflect Real Life?

Uhlig T, Norvang V, Lie E et al.Predict the Chance of Remission for Your RA Patient in Real Life. Arthritis & Rheumatism. 2014;66(1)-Supplement. ACR Abstract #944.

How are you defining remission in rheumatoid arthritis (RA)? The actual definition may not matter as much as other factors in predicting patients likely to reach that enviable condition, according to a study reported at the 2014 American College of Rheumatology annual meeting in Boston.

“There’s been a lack of knowledge on how ... different remission definitions compare in daily clinical practice, especially how disease duration and other factors could predict remission rates,” the consultant rheumatologist who described the results.

Till Uhlig MD, professor in rheumatology at the University of Oslo and his colleagues studied remission rates as defined by different criteria at 3 and 6 months among patients in the NOR-DMARD register, a phase IV prospective, longitudinal observational study encompassing 5 rheumatology departments across Norway.

Patients were grouped according to how long they’d had RA, with most having either a disease duration of over 10 years (n=1,532) or less than 6 months (n=1,329).

In the study of almost 5,000 RA patients, involving all Norwegian adults prescribed disease modifying anti-rheumatic drugs (DMARDs) for inflammatory arthropathies, those who’d had milder RA for less than a half year at diagnosis achieved remission within 6 months of starting treatment, Uhlig reported.

Younger age, lower disease activity with no erosions, lower fatigue scores and better physical function at baseline also independently predicted six-month remission. So, importantly, did the use of biologic DMARDs, Uhlig reported.

The majority of the patients were women (73%) with a mean age of 55 and an average disease duration of 8.5 years. Almost half started out with methotrexate (MTX) and 28% with a biological DMARD.

“Compared to non-methotrexate synthetic DMARD treatments, methotrexate did not increase the chances of remission very much, while biological treatment had a considerable effect,” Uhlig remarked. “These real life findings inform clinicians on optimal patient treatment, including the need for very early use of DMARDs.”

Although remission rates varied depending on which of the 6 criteria were applied (including disease activity in 28 joints, DAS28, and the ACR/EULAR remission criteria), the greatest number (34.3%) occurred among those with RA of less than 6 months' duration.

Women generally had a lower odds ratio for remission after 6 months, as did patients with erosive disease and current smokers, Uhlig remarked.

A large population study from Denmark presented at the same session found only slight differences in remission rates according to the ACR/EULAR criteria if patient-reported global outcomes were included or excluded, or when fatigue and pain were factored in.

However, substituting doctors' global outcomes for patient-reported global outcomes almost tripled the percentage of patients in remission, echoing numerous previous studies showing that doctors tend to be more likely to rate patients as in remission than do the patients themselves. This underscores the importance of including of patient experience in remission criteria, the Danish researchers conclude.