Is It Time to Banish Composite Measures for Remission in Rheumatoid Arthritis?

Patient‐Reported Outcomes in Rheumatology Patients With Limited English Proficiency and Limited Health Literacy

“…The value of the PGA has been questioned in recent years because of the issues detailed above and for the fact that it is often the sole variable preventing the achievement of remission . It remains in use, however, in most common disease activity indices . As opposed to measuring disease activity, functional status assessment measures (FASMs) are a measure of a patient's functionality, which can measure cumulative damage over years .…”

“…Many editorials have encouraged that its prominent role in RA research and practice be reconsidered . Despite these issues, the PGA remains, for the time being, part of nearly all RA composite disease activity indices .…”

Patient Global Assessment of Disease Activity and Radiographic Progression in Early Arthritis: Three‐Year Results From the ESPOIR Cohort

“…Achieving and maintaining these targets has been shown to lead to better outcomes for patients (4). However, important knowledge gaps remain, namely regarding how to define remission (5,6) or how strictly to pursue it in practice.

In early arthritis, sustained Boolean 4‐variable remission was achieved less frequently (7%) than patient global assessment (PtGA) near remission (12%; low joint counts and C‐reactive protein levels and only PtGA score of >1 of a maximum possible score of 10). A status of 4‐variable remission over 1 year led to lower structural progression at 3 years (29%) than a status of PtGA near remission (45%); however, this difference was not statistically significant. PtGA was not associated with radiographic progression when taken separately. Both 4‐variable remission and 3‐variable remission (all the same variables comprising 4‐variable remission except PtGA) appear useful targets when aiming for structural nonprogression (71% and 61%, respectively).

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“…Current remission criteria for RA, endorsed by the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR), include a Boolean‐based definition based on very low thresholds for 4 variables (4‐variable remission): a swollen joint count in 28 joints (SJC28) of 0 or 1, a tender joint count in 28 joints (TJC28) of 0 or 1, a C‐reactive protein (CRP) level ≤1 mg/dl, and patient global assessment of disease activity (PtGA) score of ≤1 of a maximum possible score of 10 (7). Several issues with PtGA have been raised, including its difficult interpretation and low correlation with disease activity (8), leading to controversy regarding its inclusion in composite indices (6,8,9). A recent analysis of a large data set (n > 27,700 patients) indicated that the proportion of patients whose disease failed to reach remission solely due to having a PtGA score of >1 (PtGA near remission) was about twice as high as compared to those attaining full 4‐variable remission, which means that removing PtGA would almost triple the remission rate (from 6% to 16%) (10).…”

Current Treatment Strategies in Rheumatoid Arthritis After Methotrexate Are Not Enough to Maintain Sustained Remission: There Is No Holy Grail!

“…Defining remission using the DAS28 using the C‐reactive protein level leads to more patients achieving remission than using a more stringent metric such as the SDAI. Many remission definitions include a patient‐reported outcome (PRO) such as patient global assessment, which if removed would result in more patients being classified as in remission, since the patient global assessment is often strongly related to pain, which may be driven by factors unrelated to active RA (i.e., not from clinically detected inflammation) (12). If remission was defined as no detectable disease on metrics such as the CDAI, in combination with a PRO such as the Routine Assessment of Patient Index Data 3 and no detectable inflammation on imaging, then remission would be very rare.…”