Q: What is Remission of Rheumatoid Arthritis?
It is not so with Rheumatoid Arthritis. They haven’t really decided what it is. Look at what one rheumatologist said: “To a considerable extent, defining remission in RA is like defining pornography; we have great difficulty agreeing on a definition.”
How many RA patients go into remission?
That depends upon who you ask.
According to NIH, rates of remission of Rheumatoid Arthritis vary from under 5% to over 16% because of differing definitions. Those ranges are substantiated by much of what I have read. One study reported on Medscape says the remission rate can be up to 20% using certain criteria. Compare that to what one doctor said in Arthritis Today: “If you get treated within two years of the onset of RA symptoms, you have more than a 50 percent chance of achieving remission.”
Is he saying that over half of those who are treated early (during the first 2 years of RA) will get remission?
Alas, I am not a doctor. But, I have read dozens of abstracts and detailed reports on remission. I have never read anything like that, however he qualifies it.
It also depends upon how you ask.
There are various sets of criteria which fulfill various definitions of remission. NIH concluded: “The use of different definitions of RA remission leads to different results with regard to remission rates…”
Two broad definitions of remission with one basic distinction
1) There is a generic understanding of “remission” with a connotation that we all know. One online dictionary defines remission as the “absence of symptoms of the disease and return to good health.” In part, Wikipedia says, “a cure(that) is the end of a medical condition.”
2) There is a big difference between that and what rheumatologists often call “clinical remission.” They are referring to a specific set of criteria which usually does not include the “absence of symptoms” or a “return to good health” or a “cure.”
Hopefully, I did not confuse you. Here’s a link to a wide-ranging set of definitions of remission of Rheumatoid Arthritis. It gives 6 different descriptions of clinical remission with varying criteria. It is at Science Direct. Rheumatology doctors look for something that they call “clinical remission.” And there are several different descriptions of clinical remission. As I mentioned at the end of yesterday’s post, Science Direct has listed 6 different descriptions of clinical remission of Rheumatoid Arthritis.
The American College of Rheumatology adopted a list in 1981 of six criteria. If 5 out of 6 of them were satisfied for 2 months time, that was classified as a clinical remission. In 2007, the ACR adjusted the list and the standard. It is now 4 out of 5 criteria, making it easier to classify people as being in a state of remission. “No fatigue” was removed from the list.
Here is a look at the current ACR remission criteria:
Complete clinical remission is defined as presence of at least 4 of the following 5 criteria for at least 2 consecutive months:
* morning stiffness equal to 15 minutes or less
* no joint pain by history (meaning according to patient)
* no joint tenderness
* no joint or tendon-sheath swelling
* ESR lower than 30 in women (20 in men)
Note: Please see my recent posts on tests for RA regarding ESR and CRP levels.)
What difference does it make?
Rheumatoid Arthritis damage can continue to in the patient.
Researchers are beginning to realize that even patients who appear to be in a period of clinical remission are possibly continuing to experience damage due to RA. According to one RA study in the Netherlands, “Whether radiographic progression (that is x-ray changes revealing damage) is entirely dependent on the presence of joint inflammation is a matter of debate; some evidence suggests that radiologic progression may continue in patients who appear clinically to be in remission…”
This would mean that the patient should definitely not suspend treatment aimed at forestalling damage. And it would beg the question of whether the use of the term “remission” is actually appropriate to begin with.
The authors point out the obvious need for better methods of detecting joint damage. “Better diagnosis of joint damage will assist in our quest to attain and document full remission in RA.”
The criteria doctors use to judge the state of Rheumatoid Arthritis in a patient directly affect treatment decisions. Patients who are considered to be in remission are usually assigned a less aggressive treatment protocol. As stated above, unseen damage to joints and other body systems can continue while inflammation appears to have abated.
Here is one example: “Rheumatoid arthritis is a major risk factor for heart attack as a study of 114,000 women indicated. The risk of a heart attack in women with rheumatoid arthritis was double that of other women” (Medterms RA article).
My question: Does so-called “clinical remission” have any influence on this statistic? Mortality rates for Rheumatoid Arthritis say, “No.” See my post on RA and mortality.
This one is thorny. The criteria that a pharmaceutical company uses for its drug trials make the drug to appear more or less effective. If one drug trial uses a stringent definition of clinical remission, its product may appear to be less effective than another company which uses a more relaxed standard.
An amusing account of ankles.
I read a couple of articles about an interesting debate that took place over the last couple of years. Rheumatologists were arguing that joint counts (swollen, tender, or disabled) ought not include feet and ankle joints. One elaborate study “proved” that it does not matter whether ankles and feet are counted. In other words, there is no difference in the DAS (disease activity score) as it relates to criteria for remission according to NIH Rheumatoid Arthritis statistics.
Read their conclusion for yourself: “…inclusion of ankles and feet only rarely influences the definition of overall disease activity status, especially the presence or absence of remission.”
Here is the funny part. This is a direct quote. I promise you. It is a footnote to the study above:
“Finally, an important clinical consideration should be discussed. The mere fact that ankles and feet have been excluded in the context of certain composite scores does not justify their omission in the evaluation and management of individual patients with RA. In contrast, since their involvement is common and they bear highly important functional roles…”
They are reminding doctors who read their report to go ahead and treat the ankles and feet because they are functionally very useful parts of the body of the person affected. I find it hysterically funny that they consider it necessary to say such a thing.
The Story of Rheumatoid Arthritis Remission
Once upon a time, there was no effective treatment for Rheumatoid Arthritis. Eventually, various substances were found to assuage some symptoms, at least slightly. And then one day, doctors thought they had found a cure in cortisone. However, they soon learned that they were mistaken.
During our lifetime, substances have actually been engineered by scientists to have a great effect upon most people with RA. Symptoms of RA can often be decreased enough to enable some RA’ers to live a life that can appear almost normal – to total strangers anyway. This has brought notions of remission into the scope of treatment goals for RA.
History of RA Treatment Goals
1) The first goal was clear: make Rheumatoid Arthritis patients feel better.
2) Disability was generally treated with surgery.
3) Increasingly, however, the goal of treatment for RA has become to thwart joint damage.
4) More recently, “clinical remission” has become a typical goal of RA treatment.
5) I believe it is also important to discover ways to prevent the harm that Rheumatoid Arthritis does to other body systems in order to extend life expectancy.
6) My desire is to make a cure for Rheumatoid Arthritis the primary goal of research and then treatment.
If we are not sick, why do we still have to take medicine?
Clinical remission of Rheumatoid Arthritis does not mean cure. If you have followed Parts 1 and 2 of this series, then you have realized that by now. Medication can reduce symptoms by a certain percentage. If that reduction is great enough, then it may be labeled “clinical remission.” That is distinct from an organic remission which is spontaneous and not drug induced. Either kind of remission is temporary in almost every case. (See The Four Courses of Rheumatoid Arthritis, Part 1.)
Here is where you are glad that this blog is written by a real live RA’er.
Why on earth do they get to call this remission?
1) RA’ers in clinical remission are expected to continue to use strong medications (including DMARDs and steroids) which have powerful side effects and can cause serious damage. They live with the side effects, expense, and regular blood tests that the medications bring.
2) The damage of Rheumatoid Arthritis can continue during the so-called remission to both joints and other body structures. RA probably will still affect the lifespan of the patient.
3) What if cancer patients in remission had to continue receiving chemotherapy, radiation, or surgery? Would they question the use of the term remission?
Maybe remission is just not the correct word. Since there is a reduction of symptoms, and contraction of some indicators, and a slowdown of the disease progression, I have thought of a better word. If Rheumatoid Arthritis were an economy, they would call it a recession. How about calling it a “clinical recession”?