Monday, September 2, 2013

Remission in Rheumatoid Arthritis - Is it Possible?

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis. It is a chronic, autoimmune driven, systemic disease that affects approximately two million Americans.

While it is obviously a painful debilitating condition, RA also negatively impacts the quality of life and reduces functionality in affected individuals.

The goals of treatment are pretty straightforward. They are to reduce pain and inflammation, prevent further deterioration of joint damage, and restore functional capacity.

The advent of newer biologic drugs has enabled rheumatologists to offer remission- the absence of disease- to their patients with RA.

Aside from the symptomatic relief and restoration of function, there are other significant benefits of remission induction, They are extension of life span, since several studies have correlated disease activity with structural damage and structural damage with reduced functional disability status and reduced functional disability with shortened lifespan.

Also, the reason for this shortened lifespan appears to reside not only in functional status, but also in the accelerated cardiovascular disease that patients with active RA have.

So, it is imperative that patients with RA undergoing treatment be monitored to ensure they achieve remission.

The problem is that there are so many methods of disease activity measurement and there is no consensus among rheumatologists as to which measurement tool is the best.

Nonetheless, the two most common methods for quantifying disease activity are the American College of Rheumatology criteria and the Disease Activity Score. An additional measurement device is the Health Assessment Questionnaire (HAQ) which is designed to look at functional status only.

Each of these tools has its strengths and weaknesses.

It is clear from a number of studies that remission has many definitions, depending on who you talk to. It is also pretty clear that even a low grade amount of disease can still lead to poor outcomes because joint damage is still progressing and that eventually leads to long term disability.

Another problem is that the measurement devices mentioned above are cumbersome and difficult to routinely use in an office or clinic setting. Also, consistency of measurement can be an issue. What is a "1" to one rheumatologist may be a "2" to another.

On the other hand, biologic drugs are extremely expensive and many physicians as well as patients are not easily swayed by long term data but are more concerned with how they feel and function in the moment. This becomes even more of an issue as some rheumatologists offer "drug holidays" to patients who are "in remission."

A recent study from the Annals of Rheumatic Disease studied a group of patients with severe RA who had remission established with infliximab (Remicade) and then had the drug discontinued and still remained in remission.

The measurement devices they used were the DAS 28, x-rays, and HAQ. They concluded, "that more than half of patients who maintained a low disease state for more than 24 weeks on infliximab could discontinue the drug for a year or longer without radiographic or functional disease progression."

Bottom line: You can't go wrong shooting for remission. It may be possible to take a "drug holiday." There needs to be a balance between the goal of total remission and practical life style considerations.

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