Association of 17 Definitions of Remission with Functional Status in a Large Clinical Practice Cohort of Patients with Rheumatoid Arthritis

Abstract

Objective.To compare the association between different remission criteria and physical function in patients with rheumatoid arthritis followed in clinical practice.Methods.Longitudinal data from the METEOR database were used. Seventeen definitions of remission were tested: American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean-based; Simplified/Clinical Disease Activity Index (SDAI/CDAI); and 14 Disease Activity Score (DAS)-based definitions. Health Assessment Questionnaire (HAQ) ≤ 0.5 was defined as good functional status. Associations were investigated using generalized estimating equations. Potential confounders were tested and sensitivity analyses performed.Results.Data from 32,915 patients (157,899 visits) were available. The most stringent definition of remission was the ACR/EULAR Boolean-based definition (1.9%). The proportion of patients with HAQ ≤ 0.5 was higher for the most stringent definitions, although it never reached 100%. However, this also meant that, for the most stringent criteria, many patients in nonremission had HAQ ≤ 0.5. All remission definitions were associated with better function, with the strongest degree of association observed for the SDAI (adjusted OR 3.36, 95% CI 3.01–3.74).Conclusion.The 17 definitions of remission confirmed their validity against physical function in a large international clinical practice setting. Achievement of remission according to any of the indices may be more important than the use of a specific index. A multidimensional approach, targeted at wider goals than disease control, is necessary to help all patients achieve the best possible functional status.

Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients

“…In higher disease activity states, both PGA and HAQ-DI predominantly reflect disease activity. In remission, they are expected to remain correlated, even if one assumes (as we do) that neither of them substantially reflects inflammation at this stage, because they are essentially determined by similar subjective factors and comorbidities [9,14,17,39] It follows that, irrespective of disease activity, PGA is bound to predict HAQ-DI, and this obviously questions the use of HAQ-DI to assess the use of PGA, especially in a definition of remission, if it is intended to guide decisions on immunosuppressive therapy. The current results confirm this interpretation: How else could we coherently explain that, also in our study, 4V-remission is associated with significantly higher prevalence of GFO than 4V-near-remission if these two conditions share similar levels of SJC28, TJC28 and CRP (all ≤1) and similar levels of radiographic progression?…”

Rheumatoid Arthritis from Easy to Complex Disease: From the “2022 GISEA International Symposium”

“…However, there is not only one univocal definition of remission and it remains a very heterogeneous state, which would require an effort for a clear and precise definition [35]. In particular, Boolean remission stratifies RA patients into a deeper grade of remission than Simple Disease Activity Index (SDAI) or Clinical Disease Activity Index (CDAI) remission definition, which in turn give a more stringent grade of remission than Disease Activity Score (DAS) or DAS28 [36]. Moreover, recently Boolean remission definition was revised by ACR/EULAR increasing the PtGA threshold from 1 (Boolean1.0) to 2 (Boolean2.0) (within a range of 0-10) to improve the agreement with index-based remission criteria without compromising the predictive value for radiographic or functional outcomes [37] The different grade of remission gives the opportunity to sort RA patients and to adequately treat them, reducing the risk of joint damage and damage progression [38].…”