Rheumatoid arthritis researchers redefine remission

The American College of Rheumatology today announced the release of two new provisional definitions of rheumatoid arthritis remission, which are to be applied to future RA clinical trials.

According to research presented in the March issue of Arthritis & Rheumatism, a person with RA who is enrolled in a clinical trial would need to meet one of the following definitions to be considered in remission:

1. Tender joint count, swollen joint count (on 28 joint counts), C-reactive protein (in mg/dl), and patient global assessment scores (on a scale of zero to 10) are all less than or equal to one.

2. Simplified Disease Activity Index (which adds the scores from the four outcome measures above plus a physician global assessment to create one number between zero and about 100) score is less than or equal to 3.3.

According to the investigators, RA disease activity is generally characterized by joint swelling and tenderness and is also reflected by increased blood levels of C-reactive protein, which is a laboratory measure of inflammation. In addition, assessments by the patient and the health professional examining the patient also reflect the extent of disease activity. These measures, among others, have been thoroughly reviewed by the investigators of this study and helped them arrive at the above provisional definitions. These definitions are in line with the RA treatment goal of reversing disease activity to prevent future damage. More simplistically, once someone has essentially no signs and symptoms of the disease he or she would be considered in remission and should benefit from maximal reduction in physical disability and no progression of joint damage.

The ACR and the European League Against Rheumatism, together with the Outcome Measures in Rheumatology Initiative, jointly convened a committee to create a definition of RA remission that could be used by rheumatologists involved in clinical trials.

"As we have moved into a time of new treatment strategies for rheumatoid arthritis, remission has become an increasingly attainable goal," says David T. Felson, MD; an investigator in the study. "However, there has been no widely-used definition of remission that is stringent, but achievable, and that could be applied uniformly as an outcome measure in clinical trials. Understanding this disconnect between treatment advances and the current definition of remission - which was created in 1981 by the ACR - led our committee to focus on redefining remission so RA researchers could begin to test new definitions to see if they hold up in clinical trials."

At the beginning of its research, the committee agreed that remission had to meet a definition of little, if any, disease activity. Looking at the ACR's core set of disease activity measures in RA (including tender joint count, swollen joint count, patient's assessment of pain, patient's and physician's global assessments of disease activity, patient's assessment of physical function, and laboratory evaluation of C-reactive protein), each committee member was surveyed to determine what the highest cut-off point for each of these should be for a person to be considered in remission. The results of this survey led to a group of candidate definitions of remission, and each of these definitions were tested against each other and compared to the outcomes of existing RA trials.