Rheumatoid Arthritis: Defining Clinical and Ultrasound Deep Remission

Radiographic Progression in Patients with Rheumatoid Arthritis in Clinical Remission or Low Disease Activity: Results from a Swiss National Registry (SCQM)

Background/Objectives: The therapeutic aim for rheumatoid arthritis (RA) is to control disease activity and prevent radiographic progression. Various clinical scores are used to assess disease activity in RA patients. The DAS 28 score can define states of low disease activity (LDA) and remission. Despite achieving LDA or remission, radiographic progression may, nevertheless, occur. However, the rates and frequency of this occurrence have not been analyzed in detail. (1) To characterize radiographic progression in patients with persistent DAS 28-defined LDA or remission. (2) Analyze the potential benefits of modifying therapeutic strategies in response to observed radiographic progression in patients with persistent LDA or remission. Methods: An analysis was conducted on RA patients enrolled in the SCQM (Swiss Clinical Quality Management) cohort. Persistent LDA or remission was defined as DAS 28 ≤ 3.2 or <2.6, respectively, recorded at two consecutive follow-up time points. Inclusion criteria involved patients with a minimum of two sets of radiographs taken during these LDA and/or remission periods. Radiographic progression was measured using the Ratingen score, a numerical scale ranging from 0 to 190, which quantifies joint erosions. Repair was defined as a decrease in the Ratingen score > 5 points/year, while progression was characterized by an increase of >1, >2, or >5 points change in the Ratingen score within a one-year timeframe. Results: Among 10'141 RA patients, there were 1'447 episodes of remission and 2'614 episodes of LDA, with two sets of X-rays available for assessment during these episodes. The rates of radiographic progression (>5 points change in the Ratingen score per year) were 11.2% for LDA and 8.8% for remission. Therapeutic adaptations were made in 7.0% of patients in remission and 12.9% of patients in LDA following radiographic progression. After radiographic progression despite LDA, loss of LDA was observed in 19% of patients with treatment intensification versus in 8.5% under continued treatment during follow-up within 36 months. Conclusions: We report a considerable rate of radiographic progression occurring in RA patients with LDA or clinical remission. Notwithstanding minor radiographic progression, maintaining therapeutic continuity seemed more favorable than altering the therapeutic regimen.

Development of a novel clinimetric tool: PAtient Reported Disease Activity Index in Rheumatoid Arthritis (PARDAI-RA) by PANLAR, for the assessment of patients living with rheumatoid arthritis

BACKGROUND

Clinical experience has shown that a single measure is not sufficient to assess disease activity in rheumatoid arthritis (RA). Various clinimetric tools are necessary to address the many clinical situations that can arise.

METHODS

In order to develop a comprehensive measurement tool, the Pan American League of Associations for Rheumatology searched for the most frequent measures of disease activity applied in RA by means of a semi-systematic review of the available literature.

RESULTS

We found that the most frequently reported measures of disease activity were the 28-joint Disease Activity Score, C-reactive protein, and the erythrocyte sedimentation rate, followed by patient-reported measures of pain and stiffness and many other composite indices and patient-reported outcome measures. The most frequent physician-reported sign of disease was the swollen joint count, and the most frequently self-reported feature was the increase in disease activity or flares.

CONCLUSION

In this article, we present a new clinimetric tool developed based on expert consensus and on data retrieved from our search. Disease activity can be better assessed by combining various data sources, such as clinical, laboratory, and self-reported outcomes. These variables were included in our novel clinimetric tool. Key Points • The goal of treatment of RA is to achieve the best possible control of inflammation, or even remission; therefore, disease management should include systematic and regular evaluation of inflammation and health status. • Clinimetric tools evaluate a series of variables (e.g., symptoms, functional capacity, disease severity, quality of life, disease progression) and can reveal substantial prognostic and therapeutic differences between patients. • Our clinimetric tool, which is based on a combination of data (e.g., clinical variables, laboratory results, PROMs), can play a relevant role in patient assessment and care.

[Innovative strategies for treatment of rheumatoid arthritis]

Besides excellent guidelines and newly developed highly effective drugs, evidence-based strategic use of these new drugs has especially contributed to enormous advances in rheumatoid arthritis treatment, apparent especially since 2000. Currently, the treat-to-target (T2T) strategy has proven to be the most successful in several studies and systematic reviews. The target is to achieve remission, which should be reached and sustained for an optimal outcome (i.e. stable over a long time period). If the initial disease-modifying antirheumatic drug (DMARD) treatment fails, the best strategy for continuing treatment is controversial, with swap or switch being open to debate (change within a class of drugs or change in the mechanism of action). Recent studies seem to indicate that switching to another mechanism of action is the most successful approach. A hotly discussed topic is the question whether DMARD treatment can or should be tapered when sustained remission has been achieved? Many patients wish for a reduction of drugs in cases of stable remission; however, the stable disease control might become destabilized by tapering. The main priority is the reduction or tapering of glucocorticoid treatment. When the decision for reduction of DMARD treatment is made together with the patient, a complete cessation bears a high risk of a flare, therefore, a careful step by step reduction of DMARD treatment should be preferred. In the case of a running combination, the question whether the conventional DMARD (mostly methotrexate), the biological (b)DMARD or targeted synthetic (ts)DMARD should be reduced first, must be decided on an individual basis. Most patients prefer to first reduce methotrexate and transfer to a monotherapy.