Thursday, September 3, 2009

What is Remission of Rheumatoid Arthritis? Part 2

Clinical Remission

Rheumatology doctors look for something that they call “clinical remission.” And there are several different descriptions of clinical remission. As I mentioned at the end of yesterday’s post, Science Direct has listed 6 different descriptions of clinical remission of Rheumatoid Arthritis.

The American College of Rheumatology adopted a list in 1981 of six criteria. If 5 out of 6 of them were satisfied for 2 months time, that was classified as a clinical remission. In 2007, the ACR adjusted the list and the standard. It is now 4 out of 5 criteria, making it easier to classify people as being in a state of remission. “No fatigue” was removed from the list.

Here is a look at the current criteria:

Complete clinical remission is defined as presence of at least 4 of the following 5 criteria for at least 2 consecutive months:
- morning stiffness equal to 15 minutes or less
- no joint pain by history (meaning according to patient)
- no joint tenderness
- no joint or tendon-sheath swelling
- ESR lower than 30 in women (20 in men)

Note: Please see my recent posts on tests for RA regarding ESR and CRP levels.)

What difference does it make?

Rheumatoid Arthritis can continue to damage the patient.

Researchers are beginning to realize that even patients who appear to be in a period of clinical remission are possibly continuing to experience damage due to RA. According to one study in the Netherlands, “Whether radiographic progression (that is x-ray changes revealing damage) is entirely dependent on the presence of joint inflammation is a matter of debate; some evidence suggests that radiologic progression may continue in patients who appear clinically to be in remission…”

This would mean that the patient should definitely not suspend treatment aimed at forestalling damage. And it would beg the question of whether the use of the term “remission” is actually appropriate to begin with.

The authors point out the obvious need for better methods of detecting joint damage. “Better diagnosis of joint damage will assist in our quest to attain and document full remission in RA.”

Patient treatment

The criteria doctors use to judge the state of Rheumatoid Arthritis in a patient directly affect treatment decisions. Patients who are considered to be in remission are usually assigned a less aggressive treatment protocol. As stated above, unseen damage to joints and other body systems can continue while inflammation appears to have abated.

Here is one example: “Rheumatoid arthritis is a major risk factor for heart attack as a study of 114,000 women indicated. The risk of a heart attack in women with rheumatoid arthritis was double that of other women” (Medterms).

My question: Does so-called “clinical remission” have any influence on this statistic? Mortality rates for Rheumatoid Arthritis say, “No.” See my post on Mortality.

Drug trials

This one is thorny. The criteria that a pharmaceutical company uses for its drug trials make the drug to appear more or less effective. If one drug trial uses a stringent definition of clinical remission, its product may appear to be less effective than another company which uses a more relaxed standard.

An amusing account of ankles.

I read a couple of articles about an interesting debate that took place over the last couple of years. Rheumatologists were arguing that joint counts (swollen, tender, or disabled) ought not include feet and ankle joints. One elaborate study “proved” that it does not matter whether ankles and feet are counted. In other words, there is no difference in the DAS (disease activity score) as it relates to criteria for remission according to NIH.

Read their conclusion for yourself: “…inclusion of ankles and feet only rarely influences the definition of overall disease activity status, especially the presence or absence of remission.”

Here is the funny part. This is a direct quote. I promise you. It is a footnote to the study above:

“Finally, an important clinical consideration should be discussed. The mere fact that ankles and feet have been excluded in the context of certain composite scores does not justify their omission in the evaluation and management of individual patients with RA. In contrast, since their involvement is common and they bear highly important functional roles…”

They are reminding doctors who read their report to go ahead and treat the ankles and feet because they are functionally very useful parts of the body of the person affected. I find it hysterically funny that they consider it necessary to say such a thing.

Or maybe just sad.

Next time: Remission and RA, part 3. We’ll ask, “Are we still sick if we are in remission?”


MissDazey said...

Well, my ankles are useful although I never know how well they will function. In fact the last doctors visits I've had, with 3 different doctors and a nurse practitioner, my ankles were swollen double. None of them would say for certain what caused it, all said it was a combination of all that ails you..(in more medical language, of course.)

I don't understand most of the medical stuff, just over my head. Most of the time just happy not to understand it. In fact I couldn't explain the term "a flare" to a friend.

tharr said...

If they don't include my feet and ankles, I'm immediately 40-50% better. I have severe damage in both feet and ankles from RA (and I have broken my right ankle twice racing), how could they exclude these in their study?

Kelly said...

It's actually worse than that.
They do not exclude them from the study.
THEY ARE EXCLUDING THEM FROM YOUR DISEASE ACTIVITY SCORE (DAS) which they use to judge how active is your RA is.
what about that?
btw: this is the tip of the iceberg. At least they are saying that those joints can be counted for your "treatment"!