Several other assessments of the remission criteria in other data sets are on the way, Dr. O’Dell said. "I’ve heard of them, and people are talking about them," and these reports will likely appear in the literature over the next year. Advance word is that the remission criteria "stood up very well," Dr. O’Dell added.
Is Remission the Right Goal?
The last comment from the Brigham and Women’s group raises the important question of whether remission is the best target for most RA patients or is low disease activity enough.
"About 10%-20% of patients in trials reach remission according to the new definitions. Newly diagnosed patients tend to have disease that is more responsive to treatment, so that the proportion achieving remission is likely to be higher, but probably not reaching 40%," said Dr. Felson. "In trials, regimens will target" the new ARC/EULAR definition, "but I’m less sure about this as a target for patients [in routine practice]. It may be difficult for many patients to reach this threshold, even with optimal current treatment."
For the time being, in patients with an established RA diagnosis using MRI or ultrasound to pick up inflammation that is not clinically apparent "is not practical," said Dr. O’Dell. One area where joint imaging may be especially helpful is in patients who are doing well on treatment and can be considered for tapering down treatment. Studies are now looking at whether ultrasound or MRI can identify patients who are good candidates for dose reductions, Dr. O’Dell said.
"Remission, whether you define it with the new definition or an older one, is necessary for the long-term health of patients," said Dr. Furst. "The goal is preventing x-ray damage, and allowing patients to have optimal long-term function and quality of life. That’s what remission criteria are all about: They give physicians a measuring stick for telling how well a patient is doing" with respect to these long-term treatment goals. "There is always a balance between achieving these goals and making sure the patient is not harmed" by aggressive treatment. The ACR/EULAR criteria "emphasize the need to quantify patient response, and in that sense they are slowly changing practice," Dr. Furst said.
"There is no doubt that there is increasing movement toward treating to a target, but most rheumatologists don’t believe that remission is the right goal for every patient." said Dr. O’Dell. "We’d love to have remission, but sometimes it’s more problematic than it’s worth. What we don’t know is the long-term difference between a patient who is barely in remission compared with one who is close but not in remission. How far should we push it? If the patient is not having trouble with treatment, then we should definitely push it. If a patient is on 20 mg/week of methotrexate and is nearly there, then trying 25 mg of methotrexate/week is clearly the right thing to do in most patients. But if the patient is not at remission but also is not always tolerating 20 mg/week, if they don’t feel good the day after their dose, what’s the right answer? We don’t know; it’s clinical judgment."
Dr. Felson, Dr. O’Dell and Dr. Wolfe said they had no disclosures. Dr. Furst said that he has financial relationships with Abbott, Actelion, Amgen, Biogen Idec, Bristol-Myers Squibb, Centocor, Genentech, Gilead, GlaxoSmithKline, Merck, Nitec, Novartis, Roche, UCB, Wyeth, and Xoma.