Remission. We all strive towards it, dream of it, wonder why we aren't there yet. When you have RA, the word remission is everywhere, but what exactly is it? How is it defined, how do you get there and what if you haven't yet seen any signs of it? To get more answers, I spoke to Dr. Yusuf Yazici, assistant professor rheumatology and head of Clinical Outcomes Research Unit at the NYU Langone Medical Center. Much of the discussion was framed by your questions.
One note: please keep in mind that the statements made in this post about treatment and remission are general ones. To discuss your specific case of RA, your treatment and questions about remission as they pertain to you, please consult your rheumatologist.
Definition of Remission
"Remission means absence of disease activity." Dr. Yazici said. In cases of RA, "spontaneous remission very rare and it happens early in the disease when the disease is not fully formed." He went on to say that "it's likely that those don't have rheumatoid arthritis, they have something else that goes into remission."
In terms of remission, Dr. Yazici stated that "currently in rheumatoid arthritis we talk about remission while you're on medication. If you stop medication, 95 percent of the time, the RA comes back." He went on to confirm the need for early, aggressive treatment, stating that those that "get on meds and respond within first 12 months have the best response."
When you treat hypertension or diabetes, a single number can be used as a measurement to indicate whether a patient is doing well. However, with RA there is no single number and rheumatologists use composite indices to measure whether a patient is in remission. This means different measures used together, such as number of swollen joints, number of tender joint and a blood tests indicating level of inflammation in the body. This is where it gets interesting and potentially little confusing, because there are five measures of remission commonly used by rheumatologists. "If someone is in remission, the next question is by which measure?" Dr. Yazici said.
Yazici went on to explain that these five common measures all have their own definition of remission and the overlap between them is approximately 80 percent. That means that although they might disagree on a few measures of remission, 80 percent of the time, they do agree. The most stringent of the measures is the new remission criteria developed by a committee of members from the American College of Rheumatology and European League Against Rheumatism (ACR/EULAR). These criteria define remission if you have
- no more than one swollen joint
- no more than one tender joint
- you rate the overall severity of your RA 10 or less on a 0-100 scale
- your sedimentation rate blood test is low (below 30 for women and 20 for men)
I asked Dr. Yazici which of the measures was most commonly used in rheumatology practice and he indicated the Disease Activity Score or DAS-28. According to this index, you can still be considered as doing well or in remission if you have a few swollen or tender joints.
Rates of Remission and Low Disease Activity
Numerous studies have found that by the ACR/EULAR definition, only 6% of people with RA experience remission. However, this measurement is very stringent. Higher rates are possible when using different, slightly more flexible criteria. Dr. Yazici mentioned that the best remission rates that are currently achieved are 40-50 percent.
Low disease activity can also be acceptable. Dr. Yazici mentioned that 15-20 percent of people who have RA also have fibromyalgia. Since fibromyalgia doesn't tend to improve to the point of remission, these individuals "will always have pain so their tender joint count will never be zero ... they'll never be in remission by that measure, but they might have no active symptoms of RA." Each case is individual and rheumatologists will therefore look at a number of factors in determining whether someone is in remission. Dr. Yazici went on to say that "well controlled RA is similar to remission in a lot of cases."
How to Get to Remission
Dr. Yazici said "the main thing is not the medication you use, but how aggressively you use it. We have to keep pushing it and evaluate the patient at least every three months and not keeping people on a medication for more than six months if they're not adequately responding to it." This is the treat to target approach, "the main movement in rheumatology these days."
Dr. Yazici went on to explain that of those that reach a target of low disease activity or remission, approximately 40 percent can do so on one medication and approximately 60 percent will require a combination of medications, usually involving Biologics. Many can manage on the same medication for long time, but "50% have to change something within 5 years or so." If they switch to another medication, it is likely that they will respond well again
About 10 percent do not respond to medication. When someone does not respond, Dr. Yazici said "it has to be carefully analyzed, because they might not be taking the maximum dose, they may not have given it enough time ... [It's a matter of] right dose, right duration, right combination."
For those who do not respond to treatment, Dr. Yazici offers the hope of new medications being developed. "There are at least two more medication coming out in the next two years." He explained that the present Biologics target certain molecules, but current medications don't target everything - "there are six or seven new molecules being discussed and it's our hope that those people who are not responding to current therapies will respond to the new ones."
Our thanks to Dr. Yazici for taking the time to share information about remission and the reasons to hope for the future.
Lene is the author of the award-winning blog The Seated View.