T2T finds its first proving grounds in RA. It’s success here paves the way for introducing this management strategy to other rheumatic diseases, like Ankylosing Spondylitis, Psoriatic Arthritis, Gout, and even SLE.
In my today’s overview of current thinking in RA management, it’s important to begin by reviewing the evidence on whether this cornerstone strategy in Rheumatology for over a decade actually works.
So what are the outcomes we seek to determine whether a T2T strategy works? They are:
1) fast relief of symptoms and early return to normal functions;
2) no/low disease activity;
3) no/slowed progression of joint damage.
In a nutshell, full clinical remission, or at least very low disease activity, is needed to deliver such outcomes. The previous post addressed all that.
Now that it is evident that a T2T strategy does indeed deliver better longterm outcomes to patients, the next task is to determine what the target (REMISSION) should look like:
1) It started with a disease activity score (DAS44/DAS28) incorporating swollen/tender joints count, laboratory tests for inflammation, and the doctor’s and patient’s overall assessment (or gut-feel);
2) With effective treatments like the biologics, especially in early disease, we were emboldened to aim for ever lower cutoffs of such scores. There arose proposals from some (myself included) that we should aim for deeper remission like sonographic or even histological remission;
3) When it became evident that even full clinical remission based on DAS28 <2.6 was not achievable in those with chronic disease or who have accrued significant damage, a compromise of “low disease activity” was deemed acceptable;
4) Counting 28 or 44 joints in a busy clinic with no ancillary help is no joke. Waiting for lab tests to return can hold up treatment decisions. Some new treatments like Tocilizumab and Tofacitinib may normalise lab tests better than they can treat the disease/patient. Some patients may not be able to differentiate pain from active inflammation from irreversible joint damage (Osteoarthritis) or soft tissue rheumatism (Fibromyalgia). Thus arose the varying calls to modify the scoring system by counting fewer joints, leaving out blood tests, or reducing weightage of patient input.
Amidst all this confusion, the current clinical target of remission looks something like this. If you answer “yes” to any of the following:
1) more than 1 swollen/tender joint;
2) CRP is raised (>10mg/L) ~”optional”;
3) “I feel less than 90% good about how my arthritis is affecting me” (whatever that means);
— you’re out.
EULAR Remission Slides
Given the skepticism physicians have regarding patient-reported outcomes, it should come as no surprise that developments are directed towards finding more “objective” measures of disease activity.
One is the “Targeted Ultrasound Initiative” (TUI), a movement to promote musculoskeletal training and standardisation, especially with regards to grading synovial inflammation in RA. This is envisaged to be a more accurate reflection of disease activity, available ideally at the consultation room, so as to inform clinical care at the point-of-care.
The other is this, an all-in-one lab test costing about USD1000, available from a lab out of California. It’s an expensive substitution for clinical judgment, I’d say.
Vectra DA Is Blood Test That Assesses Rheumatoid Arthritis Disease Activity
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It was a sad day when this news broke for many rheumatologists who saw ultrasound as the technical extension of their clinical acumen.
While other studies have shown ultrasound to be useful for early diagnosis and even to guide tapering of treatment, it seems that it adds nothing but costs (of service and of more biologic use) when a treat-to-sonographic-target of remission strategy is adopted.
Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial
Despite the physicians’ skepticism regarding patients over-reporting their symptoms thereby skewing the clinical disease activity scores up, the latest iteration of the remission criteria left the patient global assessment in. What was left out was the physician global assessment (except if CDAI/SDAI was used instead of the far simpler boolean measure).
Perhaps this move was prescient. This study suggests that the patients know better after all, better than their doctors and all the sophisticated scores they’ve been doing.
So, back to the good old “How ya doin’?” score?
After achieving remission, the next goal should be to stay in remission. Therapy tapering or withdrawal is not for many, especially those who are seropositive, and with longstanding disease. Ultrasound may help in this regard. Even those who manage to taper down and go off all drugs, a third is expected to flare.
Live with hope, but temper your expectations.