What's Remission in RA?

(2015) The patient perspective on absence of disease activity in rheumatoid arthritis: A survey to identify key domains of patient perceived remission. In:

You would have thought that this was settled from the start, that the patient’s therapeutic goal is naturally the physician’s treatment target. But, no.

The rheumatologist’s treatment target is sustained complete remission (CR), and if this is not achievable, then longterm low disease activity (LDA). This mantra is based on numerous high quality studies showing that amelioration of inflammation prevents joint damage and reduces cardiovascular risk, thereby forestalling eventual physical disability and premature mortality.

Patients just want to be happy; that means to be cured: drug-free remission. If this is not possible, then they’ll settle for the consolation prizes of complete symptom relief (pain, stiffness, fatigue) and full restoration of function (mobility, independence, work); with medicines that won’t kill them or cost an arm and a leg.

The next time rheumatologists start pontificating about the strategies and drugs for treating-to-target, it is not rude but pertinent to ask, “Whose target are we talking about?” Afterall, it’s the patients’ disease to live with, their complications to bear, their side-effects to suffer, and their costs to pay. Surely their perspective on disease activity and treatment should matter the most.

Comparison of clinical, patient-reported outcomes shows variability in RA treatment response

Among methotrexate-naïve patients or those who had few previous doses of the treatment, investigators…

Currently used clinical outcome measures underestimate patient reported outcomes:

“The deeper the response, as measured by CDAI and SDAI, the more likely the patient is to improve their physical function as measured by the HAQ-DI”

Tight control of disease activity fails to improve body composition or physical function in rheumatoid arthritis patients


Muscle vs Fat Mass and Physical Functioning in RA

Estimates of appendicular lean mass that are adjusted for adiposity demonstrate stronger positive…

So, this is what it comes down to: patients want their lives back, but rheumatologists are focused on damage control. 

However, inflammation suppression adequate to prevent clinically relevant damage progression is apparently inadequate to restore full function and the former quality of life.  If this is the patient’s expressed goal, then we need to dig deeper, to achieve deeper remission.  We may also need to harness regenerative medicine and reconstructive surgery to restore what is irretrievably damaged.

We have the tools (biologics, small molecules) to dig deeper. This is where imaging (ultrasound and MRI) can guide us on how deep we need to dig. This puts paid to doubts on the role of ultrasound in guiding a treat-to-remission-target strategy.

Start with the end in mind: Define your REMISSION.