To arrive at the definition of remission, perhaps it is best to discuss how the field of Rheumatology has managed to get to the point of even talking about remission. Those of us who remember those days when the only treatment for rheumatoid arthritis was aspirin and hot paraffin treatment, also remember that to speak of remission was considered by many an audacious act.
However, in the past twenty years a couple of breakthroughs allowed for improvement in the treatment of rheumatoid arthritis:
1. The development of measures of response for rheumatoid arthritis, accepted by regulatory agencies such as the United States Food and Drug Administration (FDA) and pharmaceutical companies, and therefore allowing for drug studies which if positive can lead to the approval of new medications for the treatment of rheumatoid arthritis. The tool to measure rheumatoid arthritis had been discovered.
2. Advances in the biotechnology field, leading to "biologic" treatments for rheumatoid arthritis, such as Humira, Enbrel, and Remicade; these drugs are some of the most effective therapies developed for rheumatoid arthritis.
In other words, remission suddenly became not audacious, but a reality.
One of the first well-done studies to show remission was the trial of Enbrel and methotrexate in combination for the treatment of rheumatoid arthritis. After one year, remission was achieved in 37% of the patients treated with both methotrexate and Enbrel, compared to 14% of the patients on methotrexate only.
So, how to define remission? Is part of remission a reduction in the sed rate? Does remission occur over a period time before it is called remission? Is remission truly remission if a patient is still taking medication? Even if the goal of remission is a comfortable patient, that patient can still be experiencing continued inflammation as seen on MRI, which can lead eventually to structural damage and deformities. So, remission should include radiologic evidence of quiet disease.
A recent study showed that sustained remission is associated with a halt of joint damage, no matter the type of therapy. The shorter the period of remission, the more likely at least some mild progression may be found. Thus, sustained remission is the ultimate goal to prevent the occurrence of joint destruction-and therefore disability-in rheumatoid arthritis.
Currently, the American College of Rheumatology preliminary criteria for remission in rheumatoid arthritis does not consider radiologic findings, but does include:
A minimum of 5 of the following for at least 2 consecutive months:
1. Morning stiffness not to exceed 15 minutes.
2. No fatigue.
3. No joint pain.
4. No joint tenderness or pain on motion.
5. No soft tissue swelling in joints or tendon sheaths.
6. ESR (sed rate) less than 30 mm/hour in women or 20 mm/hour in men.
Currently, the American College of Rheumatology and the European League Against Rheumatism are collaborating on defining remission in rheumatoid arthritis. This new definition should be strict, and based on no or very low disease activity, and validated against long-term outcomes, including physical function and x-ray changes. Treatment should not be part of the remission definition. This collaborating group of experts feel that there should be perhaps two definitions of remission, one defining remission for patients enrolled in clinical drug studies, and the other for the patients seen in the rheumatologist's office.
The definition of remission, alas, remains a moving target. We rheumatologists see it, but we can't quite nail it. Every time we think the answer is at hand, new information makes us realize we should not be so confident that all is well with our patients' joints.
While patients and doctors wait for the experts to come down from the mountaintop with all the answers, treatment should aspire to the idea of remission, looking toward the absence of joint pain and swelling, the absence of morning stiffness, and the elimination of fatigue. In other words, the absence of the complaints that brings rheumatoid arthritis patients to their doctors in the first place.
