Remission. We all strive toward it, dream of it, wonder why we aren't there yet. When you have rheumatoid arthritis (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 the answers, I spoke to Dr. Yusuf Yazici in a telephone interview. Dr. Yazici is assistant professor of departments of medicine (rheumatology) and hospital for joint diseases and medicine at New York University. Much of the discussion was framed by your questions.
One note before we get started: 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, consult your rheumatologist.
Definition of remission
"Remission means absence of disease activity," Dr. Yazici said. In cases of RA, "spontaneous remission is 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 said: "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 who "get on meds and respond within the 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 such single number. Therefor, 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 joints, and blood tests indicating level of inflammation in the body.
This is where it gets interesting and potentially confusing. 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.
Dr. Yazici went on to explain that these five common measures each have their own definition of remission, and the overlap between them is approximately 80 percent. In other words, 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 set of remission criteria endorsed by the American College of Rheumatology (ACR). They were developed by the ACR and the European League Against Rheumatism (EULAR) to standardize remission definitions so the results of clinical trials would be consistent across geographical regions. These criteria were purposely designed to be extremely strict and define remission as follows:
- 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, below 20 for men)
By this standard, only six percent of people with RA achieve remission.
Dr. Yazici indicated the disease activity score or DAS-28 is the disease activity index most commonly used in rheumatology practice. According to this index, you can still be assessed 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 six percent of people with RA experience remission. However, it’s important to keep in mind that these criteria were developed for use in clinical trials and will need to be assessed and validated in clinical practice. Higher rates of remission 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 explained that 20-30 percent or more 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 unique and rheumatologists will therefor 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 keep 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 who 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 a long time, but "50 percent have to change something within five 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. 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.