Elsevier

Autoimmunity Reviews

Volume 9, Issue 3, January 2010, Pages 161-164
Autoimmunity Reviews

Methods used to assess remission and low disease activity in rheumatoid arthritis

https://doi.org/10.1016/j.autrev.2009.07.001Get rights and content

Abstract

The aim of the treatment in rheumatoid arthritis (RA) is to prevent articular damage and functional loss by decreasing the activity of the disease. The overall goal is the full suppression of the activity of the disease, also called clinical remission. The most reliable indices to assess RA activity were defined by the American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR) and the International League Against Rheumatism (ILAR) and are habitually used for the evaluation of remission. The Food and Drug Administration (FDA) established three increasingly restrictive categories of disease remission: complete clinical response, major clinical response, and remission. Then, OMERACT (Outcome Measures in Rheumatoid Arthritis Clinical Trials) advanced the concept of low disease activity state (LDAS) or minimal disease activity (MDA). Thus, those reported by FDA are the only criteria for remission which consider radiographic arrest of the disease. This review aims to describe the criteria for RA remission and to discuss their advantages and limitations.

Introduction

The progressive clarification in the pathogenesis of Rheumatoid arthritis (RA) and the subsequent biopharmaceutical discoveries, led to the establishment of more effective medications [1], [2], [3]. Indeed, successful long term use of biological agents require ongoing monitoring to avoid drug toxicity [4], [5], [6], [7]. However, since biologic response modifiers have been proved to markedly reduce signs and symptoms of the disease, better outcomes are expected, and reported. Thus, remission has become the goal of RA therapy [8].

Key point to an optimal treatment success in RA is an aggressive treatment approach to the disease [9]. Patients should be assessed at least once every 3 months, and activity should be evaluated using the proposed indices [10]. Standardized measures allow an evaluation of the disease over time with the possibility of designing a progress chart, therefore highlighting effects of treatment.

The impressive achievements in controlling RA have needed parallel development of the methods suitable to assess the results of the new medications. Adequate instruments to define remission in RA have been proposed on the basis of patients' follow-up both in trials and in clinical practice and then validated [11], [12]. To date recommendations are the result of collaborative efforts between the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). Proposed definitions for remission include clinical criteria as defined by ACR and EULAR indices and additionally radiographic arrest [13].

However, reports on results of clinical trials show a heterogeneous use of response and remission criteria. To interpret the value of the claims made in support of the efficacy of a treatment it is important to understand the significance of the different criteria for remission.

This review aims to describe the criteria for RA remission used in clinical practice and to discuss their advantages and limitations.

Section snippets

Efforts to define remission and reliability of present criteria

The evaluation of the activity of RA is often difficult and may lead to misinterpretation if not all the components of the disease are considered. Multiple indices that combine set of values are required and they result to be more informative than single variables alone [14], [15]. Many scales have been proposed for assessing the patients’ clinical status, which were addressed to the different domains of the disease: inflammatory activity, physical function and organ damage.

The most reliable

Low disease activity state (LDAS) or minimal disease activity (MDA)

As reaching and maintaining a low disease activity proved more useful than reaching important improvement from high levels of disease activity, the concept of minimal disease activity was developed, and in 2005 OMERACT proposed a definition of low disease activity state (LDAS) or minimal disease activity (MDA). LDAS corresponds to “that state of disease activity deemed a useful target of treatment by both the patient and the physician, given current treatment possibilities and limitations” [36]

Conclusions

At present, reports on results of clinical trials for RA show a heterogeneous use of both EULAR and ACR criteria.

DAS showed to fare better in clinical function as it is a continuous index. DAS28 requires a lower number of joints to be counted, and seems to be better suited for use in clinical practice but could lead to underestimating the disease. SDAI and CDAI are simplified indices derived from DAS and their criteria for remission appear to be more stringent and more specific, allowing only a

Take-home messages

  • Remission is regarded as the goal of rheumatoid arthritis therapy.

  • Disease Activity Score 44-joint count (DAS 44) showed to fare better in clinical function.

  • Disease Activity Score 28-joint count (DAS28) seems to be more suitable for use in clinical practice.

  • Simplified Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI) criteria appear to be more stringent and more specific than other criteria.

  • To date only FDA criteria consider radiographic arrest, assessed by

Acknowledgement

This study was in part supported by the Italian Medicines Agency (AIFA) within the independent drug research program, contract no. FARM5KJ9P5.

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