Background Remission has become an accepted target of rheumatoid arthritis (RA) treatment, and new remission criteria have been put forward by the ACR/EULAR requiring four criteria to be fulfilled: C-reactive-protein (CRP) ≤1mg/dl, swollen joint count (SJC) ≤1/28, tender joint count (TJC) ≤1/28 and patient global assessment (PGA) ≤1cm on a 10cm visual analogue scale. Only small proportions of patients achieve full remission by these criteria, and it is unclear whether reaching three of the four criteria (“near miss” of remission) already indicates a favourable situation.
Objectives We aimed to identify the prospective outcome of near miss patients in an outpatient clinic setting.
Methods We obtained a random single cross-sectional visit of each RA patient documented in a longitudinal RA database, and determined the remission state (full remission: 4/4 criteria; “near miss”: 3/4; or neither: <3/4) at that visit and the subsequent visit. Using the near miss population as the starting point, we identified the variable responsible for the near miss (i.e. CRP, SJC, TJC, or PGA), and the remission outcome at the subsequent visit, descriptively and by non-parametric analyses.
Results We obtained data of 928 RA patients (80% female; 56% rheumatoid-factor positive; mean disease duration: 8.4 years). On average (±SD) the two subsequent visits were 5±5 months apart; 10% and 11%,respectively, were in full Boolean remission, and 22% and 22% in a near miss status. Of patients with a near miss of remission, 40% remained in this state, 15% improved to full remission, and 45% worsened and lost their near miss status again at the subsequent visit (table). Patients missing remission because of PGA or SJC were much less likely to subsequently achieve full remission than those missing TJC or CRP (12.4% and 12.8% vs. 25.0% and 28.5%, table). Patients with a near miss of remission who subsequently achieved full remission had significantly lower scores of functional impairment (p=0.017), PGA (p=0.004), evaluator global assessment (EGA) (p<0.001) and simplified disease activity index (p<0.001) than those who did not. When near miss status was sustained, then it was due to the same variable at both visits for the great majority (CRP: 100%; PGA: 89%; SJC: 79%); the clear exception here were TJC near miss sustainers, who subsequently had the same reason for the near miss in only 20%, although the patient numbers were low in this group.
Conclusions Approximately half of the patients missing one variable for remission at a random time point, worsen until the next clinic visit. This indicates that the therapeutic goal of achieving full remission needs to be actively pursued even if a state near to remission is already present. Especially PGA and SJC seem to be significant obstacles on the way to remission.
Disclosure of Interest None Declared
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.