The medical community has created and agreed upon new guidelines that define remission for rheumatoid arthritis, or RA. It’s intended to help researchers set standards during clinical trials, but doctors say this is a milestone for patients too: The definitions underscore that remission is possible and can help patients understand when they get to that point.
“It will give a person a gauge as to how well they’re doing,” explains David T. Felson, MD, a professor of medicine at Boston University and a practicing rheumatologist who was involved in creating the new definitions. “I think there are a lot of nice things about being able to measure something and agree on its measurement – especially something that we all hope will occur more often. If we can define what we all desire, we are more likely to achieve it more often.”
Doctors say one of the big problems with the old definition of remission, created in 1981, was that it defined remission as the elimination of all disease. “That’s a very hard target. We’re more likely to be able to reach limited or small amount of disease,” Dr. Felson explains.
With that in mind, The American College of Rheumatology and the European League Against Rheumatism were part of a committee that analyzed RA clinical trial data and surveyed committee members to create two new RA remission definitions that are published in the March issues of Arthritis & Rheumatism and the Annals of the Rheumatic Diseases.
One definition says to be considered in remission, patients need to meet four goals:
1. One or fewer swollen joints
2. One or fewer tender joints
3. An assessment by the patient that on a zero-to-10 scale, the arthritis activity is one or less
4. A blood test showing little or no inflammation in their levels of C-reactive protein, a key biomarker of inflammation.
A second definition uses something called the Simplified Disease Activity Index to measure disease activity. It consists of a sum score of the four measures in the first definition plus a physician assessment.
“It’s really important. We’ve recently done so well with treatments that patients are getting into remission and now with this definition we’ll be able to assess patients,” Dr. Felson explains.
David Pisetsky, MD, a professor of medicine at Duke University in Durham, N.C., says it means a lot that RA remission is even being discussed. “Thirty years ago when I started, getting into remission was quite unusual. Now it happens frequently, so it’s good for patients to know you can get there,” he explains.
Dr. Pisetsky says some people are likely to complain that the new remission definitions don’t involve X-rays to assess permanent damage to joints. “It doesn’t bother me, but some people would say if you’re looking at damage, part of the definition should be no [further] damage,” he explains. “There are people who have had RA for a long time who have damage to their joints. A lot of time unfortunately the damage is permanent. We can get rid of inflammation and they will still be symptomatic because there is damage.”
He also says for those that can view remission as a realistic goal, there is more research that needs to be done for them.
“To me there is another question which is, how much therapy do you need to maintain remission, not just achieve it,” Dr. Pisetsky says. “That is a serious question that still needs to be answered.”