RA: Beyond Remission


This is like the ARCTIC (Aiming for Remission in rheumatoid arthritis: a randomised trial examining the benefit of ultrasound in a Clinical TIght Control) trial – in extra time (and Spain is out, whatever).

It’s like, not being entirely satisfied with the original ARCTIC conclusion that ultrasound-guided treat-to-target added nothing meaningful to guidance by conventional RA disease activity measures, the trial was modified and run over 2 years in early RA patients. This time, the targeting tools targeting remission being compared were ultrasound grey scale (0-2), ultrasound power doppler(0), DAS44, DAS28-ESR, CDAI, SDAI, ACR-EULAR Boolean (28 & 44 joints), and a novel “no swollen 44 joints”.

Unlike ARCTIC (and TaSER), in which the outcomes (clinical remission criteria) were also the targeting tools (it was like measuring the yardstick with a yardstick),the current outcomes are:
1) “no radiographic progression” (mTSS=0);
2) “good outcome” (“no radiographic progression” + “physical function better than general population’s median” — PROMIS).

It came as no surprise that ultrasound remission (both grey scale and power doppler) correlated significantly with “no radiographic progression”, an outcome only achieved by the most stringent of the clinical criteria: the ACR-EULAR Boolean (which yielded the lowest remission rate given its “strictness”).

It appeared to reaffirm the original ARCTIC conclusion that only the clinical remission criteria (excluding “no swollen 44 joints”) correlated with “good outcome”. But this is where the “measuring a yardstick with a yardstick” issue comes in again: all the clinical remission criteria incorporate a heavy dose of patient-reported outcomes (eg pain, tender joint, function), while ultrasound criteria do not. It is telling that the objective physician-assessed remission outcome (“no swollen 44 joints”) failed on both primary outcomes. An interesting aside is that clinical “low disease activity” (rather than remission) also achieved neither primary outcomes, implying that clinical remission is the superior treatment target.

So I remain dissatisfied with the methodology and the implication that ultrasound remission is inferior and thus superfluous to clinical remission as a treatment goal (with the exception of the Boolean criteria). We need another trial where the outcome(s) is not weighted in favour of any of the comparators. We need a penalty shootout where the ball is truly round.

To me, this trial demonstrates a move towards a broader definition of what a good treatment outcome ought to be (in early RA): going beyond disease remission (no inflammation and joint damage), to functional restoration, and health augmentation even.  The goalposts are being shifted.

See the source image