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Newly released guidance for defining remission in rheumatoid arthritis (RA) is expected to increase the number of patients achieving it while maintaining its ability to predict good objective outcomes.

The more relaxed criteria from the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) appeared in joint publications in and the .

Using data from four clinical trials comparing biologic RA drugs to methotrexate alone or placebo, the groups found that it was feasible to accept higher scores for patients' global assessments of disease activity -- 2.0 cm on a standard 10-cm rating scale -- as part of the definition of remission, which still maintained good agreement with remission as defined solely by clinician evaluations.

The adjusted definition retained the same correlations with the risk of radiographic progression and functional disability as seen with prior definitions, said the writing committee, led by Paul Studenic, MD, PhD, of the Karolinska Institute in Stockholm, and the Medical University of Vienna in Austria. Omitting the patient assessment altogether "worsened the prediction of good functional outcomes," the panel added.

Rationale for Change

When compared with the prior threshold for remission of a 1 cm global assessment score, the choice of 2.0 cm increased the proportion of patients achieving remission from 14.8% to 20.6% in early RA and from 4.2% to 6.0% in patients with chronic disease.

"With the validation of the threshold of 2 cm for the [patient global assessment], we propose that these revised ACR/EULAR remission criteria be adopted both for future clinical trials and as a target in clinical practice," Studenic and colleagues wrote.

Up to this point, clinical remission in RA was determined in a number of ways. One involved four evaluations: the patient global assessment, swollen joint count (SJC), tender joint count (TJC), and C-reactive protein (CRP) level. Each of these had to come in at values of 1 or less (in centimeters for the patient assessment and mg/dL for CRP).

Another approach relied on the first three of these evaluations, plus the in place of CRP. A third was based solely on a similar scoring system called the .

The 1.0-cm threshold for the patient assessment has since appeared problematic, Studenic and colleagues explained, "because some patients do not achieve it despite the absence of tender and swollen joints and an elevated CRP level."

To determine whether a higher threshold could improve the definition, the committee analyzed data from four recent trials in which a substantial number of patients achieved remission by the then-standard criteria. A total of 2,048 patients participated, including 1,101 with early RA (mean duration 0.8 years) and 947 with established disease (mean duration 7.1 years). Aside from testing different thresholds for the patient assessment (1.0, 1.5, 2.0, and 2.5 cm, as well as omitting it entirely), the requirements that CRP, TJC, and SJC not exceed values of 1 were retained.

Using 2.0 cm as the patient assessment threshold maximized the correlation with CDAI- and SDAI-based definitions and kept the correlations with radiographic and functional assessments. Moreover, the authors suggested, by expanding the number of patients seen as achieving remission, the revised definition reduces the likelihood of overtreatment, as there should be no need to add new drugs or increase dosages in such patients. Indeed, their medication regimens might even be scaled back.

Studenic and colleagues cautioned that such evaluations shouldn't dictate treatment approaches by themselves: "All measurements and their interpretations need, in any case, to be complemented by the discussion between the patient and rheumatology clinician to reflect and decide on the appropriate steps in a shared decision."

New Axial Spondyloarthritis Guideline

Also in recent days, EULAR and the Assessment of SpondyloArthritis International Society (ASAS) on axial spondyloarthritis (axSpA) management.

The revision included 15 recommendations in total. Of these, 11 either remained the same from earlier editions or involved minor wording changes. Two, however, differed substantially, and two others were entirely new.

One of the important revisions was to add Janus-associated kinase (JAK) inhibitors to the list of acceptable step-up therapies for patients not getting adequate relief from conventional medications. Previously, only tumor necrosis factor (TNF) blockers and interleukin (IL)-17 inhibitors had the groups' endorsement.

Similarly, switching to a JAK inhibitor got the greenlight for patients failing an initial step-up with biologic or targeted synthetic immunomodulators. Both of these recommendations, however, came with cautions about risks associated with JAK inhibitors, such as cancers and cardiovascular events.

For the all-new ASAS/EULAR recommendations, the groups stated that "preference should be given to a monoclonal antibody against TNF" for axSpA patients with recurrent uveitis or inflammatory bowel disease, while psoriasis patients with axSpA may benefit more from an IL-17 inhibitor.

Also new was an explicit recommendation to reconsider the axSpA diagnosis and/or to look at comorbidities (such as fibromyalgia, osteoarthritis, or depression) if patients don't respond to treatment. "Making an appropriate diagnosis of axSpA is not always straightforward," the writing committee commented. "Striving for earlier diagnoses, as we nowadays do, may have advantages but also implies that more patients with relatively milder disease, less clear and classic symptoms and a better prognosis will be recognised, and misdiagnosis is increasing."

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