BERLIN – "Near remission," which is based on joint counts and acute phase reactants, predicts disease status at 3 years in patients with early inflammatory arthritis as well as the definition of remission that was proposed by the American College of Rheumatology/European League Against Rheumatism in 2011. The ACR/EULAR definition includes patient global assessment of status, according to Dr. Laure Gossec, who presented findings from the ESPOIR trial at the annual European Congress of Rheumatology.
"Near-remission is much more frequent than ACR/EULAR remission in early arthritis. It appears from this analysis that near-remission (not taking into account patient global) predicts radiographic progression over 3 years in early arthritis, as well as ACR/EULAR remission, or as the definition of remission that takes into account patient-reported fatigue. Near-remission may be a valid predictive outcome in early arthritis," said Dr. Gossec, associate professor of rheumatology at Descartes University, Paris, who currently is a visiting scholar at Manchester (England) University Arthritis Epidemiology Unit.
The 2011 ACR/EULAR proposed definition of Boolean remission of early rheumatoid arthritis comprises one or no tender joints; one or no swollen joints; C-reactive protein (CRP) level equal to or less than 1 mg/dL; and a patient global assessment score of no higher than 1 (Ann. Rheum. Dis. 2011;70:404-13). However, last year at the 2011 Annual European Congress of Rheumatology, some authors noted that patient global assessment was often a limiting factor to reach this remission, and proposed near-remission as an alternative outcome (Arthritis Rheum. 2011, ACR Congress, abstract 2459). "The question is would we lose predictive information, by not taking into account the patient’s point of view? And reversely, should we be assessing fatigue; would that add to predictive information?" Dr. Gossec noted in an interview.
Dr. Gossec and her associates undertook the ESPOIR observational study to assess if patient reported outcomes, particularly patient global and fatigue, predict radiologic joint destruction at 3 years, in patients already in near remission as judged by their joint counts and levels of acute phase reactants. Specifically, the investigators assessed the predictive value of both the ACR/EULAR proposed definition of remission at 6 and 12 months after diagnosis as well as the definition of "near remission," which included three of the four proposed ACR/EULAR end points but did not include patient global assessment of status, and "fatigue-remission" in which patient’s self-report of fatigue substitutes for the patient global.
Dr. Gossec and her associates followed 776 patients with early arthritis. The patients underwent swollen and tender joint counts and CRP measurements at 6 and 12 months after diagnosis. In addition, they completed a patient global assessment of their status at those times and a fatigue visual analog scale assessment. The outcome was change in the total Sharp-van der Heijde score between baseline and at 3 years.
Of the 776 patients, 57 patients (7.4%) met the proposed ACR/EULAR definition of remission both at 6 and 12 months, whereas 145 patients (18.7%) reached near-remission, and only 24 patients (3.1%) reached fatigue-remission. Agreement between ACR/EULAR remission and the other definitions was moderate: kappa, 0.51 (95% confidence interval, 0.43-0.60) and 0.39 (95% CI, 0.26-0.53), respectively. Prediction of radiographic progression was similar no matter which definition of remission was used.
However, the relation between radiographic progression and remission was strongest for the definition of near remission and the proposed ACR/EULAR remission. In stepwise selection only the variables in near-remission were predictive. Thus, it appears that the strongest drivers of radiographic progression are joint counts and acute phase reactants, and that for patients already in remission for those criteria, patient-reported outcomes add little to the prediction of radiographic progression. Dr. Gossec concluded that "assessing patient-reported outcomes is important to understand the patient’s perspective, but have only some added value to predict radiographic outcomes if objective criteria are already well controlled."
Dr. Gossec reported that she has no conflicts of interest that are relevant to this project.