Background The recently developed ACR/EULAR Boolean remission criteria for rheumatoid arthritis (RA) include not only remission for joint accounts and CRP, but also for patient global assessment (assessed by a patient visual analog scale, VAS) with a threshold value of 1/10 (ref). However, patient global assessment often seems to be a limiting factor for achieving ACR/EULAR remission.
Objectives To explore the role of the patient global assessment VAS in ACR/EULAR remission: according to the disease duration, and according to the formulation used for the patient global VAS.
Methods Patients: those in the ESPOIR and COMEDRA studies. ESPOIR is a national observational cohort of patients with early arthritis (at least 2 swollen joints for less than 6 months). COMEDRA is a national multicentric clinical trial involving patients with stable RA. Definitions of remission: comparison of ACR/EULAR Boolean remission (joint accounts <=1, CRP ≤10 mg/l, patient global VAS ≤1/10) and “near-remission” (identical definition, but with a patient global VAS>1/10). Frequency of remission according to disease duration: remissions evaluated in early arthritis (at 6 months in ESPOIR) and established RA (at baseline in COMEDRA). Formulation of the patient global VAS: comparison of two usual formulations of the patient global VAS: the overall global assessment VAS (how do you feel?) and a disease activity VAS (What is the activity of your RA?) (comparison available in ESPOIR only). Statistics: Non- parametric comparisons, without imputation of missing data.
Results Description of the cohorts: Early arthritis (ESPOIR): N=732 patients, mean duration of symptoms 7.0±8.3 months; established RA (COMEDRA): N=948 patients, mean duration of disease 13.5±9.8 years. Frequency of remission according to the disease duration: in early arthritis, ACR/EULAR Boolean remission was more frequent than in established RA: respectively, 13.4% (N=98) versus 8.3% (N=79). However, near-remission was also more frequent in recent arthritis: respectively, 16.7% (N=122) versus 7.2% (N=68), p<0.0001. Formulation of patient global VAS: in early arthritis, using the disease activity VAS, patients were more often in complete ACR/EULAR remission (13.4%, N=98) and less often in near-remission (16.7%, N=122) than when using the overall global health VAS (respectively 9.1% and 20.9%).
Conclusions In this study, as expected ACR/EULAR remission but also near-remission was more frequent in EA than in established RA. This may indicate the unclarity of the concept of patient global assessment in early disease. Furthermore, the disease activity VAS seemed to have a better agreement with objective data (eg, joint counts) in EA, indicating this formulation may take less into account patient subjectivity and reference shifts in terms of overall health. Treatment decisions based on a state of remission or not, should take these results into account. Studies to explore the patient's vision on the concept of remission are also needed.
Felson DT et al. Ann Rheum Dis 2011; 70(3): 404-13.
Disclosure of Interest : None declared