Adding New Perspectives to the Kaleidoscope of Remission Criteria in Rheumatoid Arthritis

Remission has many meanings. In some medical contexts it indicates lessened disease severity. In other contexts it implies the disease has disappeared. Concepts of remission in rheumatoid arthritis (RA) reflect both models. Some definitions indicate only low disease activity states. Other definitions suggest the absence of disease, with undetectable symptoms, signs, and disease markers. Critically, remission differs from “cure,” which implies RA will never return. Current opinion favors restricting remission to patients with either no or minimal synovitis, without longterm structural or functional sequelae. The seminal report by Pinals, et al in 1981 concluded “complete” RA remission indicates the “total absence of articular and extraarticular inflammation and immunological activities”1. However, many years later, uncertainties remain on how to define genuine remission states. The introduction of new therapeutic options and strategies over the past decade has made remission an achievable goal. An immediate consequence of this perspective is the need for an accurate and uniform way to identify remission. Although there are many definitions, remission does not yet have an internationally accepted gold standard. Remission criteria differ between studies, and remission rates vary depending on the remission criteria used. We have previously noted these variations2. Some remission criteria use categorical descriptions; the original American College of Rheumatology (ACR) remission criteria are one important example1. However, these criteria are very stringent and too few patients achieve this goal to make the definition a useful outcome to discriminate between patients in clinical trial settings, or to make it a realistic outcome in the routine clinic setting. Consequently, many variants have been described. Continuous composite measures are often used to define remission; the most commonly used are the low scores using the Disease Activity Score (DAS3) or its modifications such as DAS28–erythrocyte sedimentation rate (DAS-ESR) … Address correspondence to Dr. H.Y. Ma, Department of Rheumatology, GKT School of Medicine, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RS, UK. E-mail: margaret.ma{at}nhs.net

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