What is Remission of Rheumatoid Arthritis? Part 2
Clinical Rheumatoid Arthritis 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 ACR remission 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 damage can continue to in 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 RA 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 RA article).
My question: Does so-called “clinical remission” have any influence on this statistic? Mortality rates for Rheumatoid Arthritis say, “No.” See my post on RA and 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 Rheumatoid Arthritis statistics.
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 Rheumatoid Arthritis, part 3. We’ll ask, “Are we still sick if we are in remission?”
Recommended reading:
- What is Remission of Rheumatoid Arthritis? Part 1
- What Is Joint Protection for Rheumatoid Arthritis?
- The Rheumatoid Arthritis Warrior’s RA
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
Great post! (the last one was too). I’ve had RA for more than 20 years. About 10 of those were spent in “remission.” Toward the end of the 10th year I developed a lumpy “pannus” on the outside of my right wrist — very little pain involved. The orthopedic surgeon I was sent to told me that indeed, RA could continue to damage the joints and other parts of the body while it was in “remission,” and here was the proof of that. The pannus was surgically removed to preclude the eventual impairment of that wrist and hand. And now, a couple of years later, the RA is severe and active again.
I didn’t take any RA meds during the last several years of the original, active stage, nor any during the remission. I’m back on them now — they’re a lot better than they used to be. I’ll know better now, if the disease goes into remission again, and I’ll keep taking the RA drugs. What a strange disease it is!
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?
tharr,
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”!
Wren,
Great info. Thanks for sharing your experience for the newbies who come along to check this out. It’s so hard to learn so much to be able to manage RA…
Welcome to WordPress Kelly! The Cadillac of blog sites.
I laughed when I read the ankle bit. I’ve had achilles surgery on both ankles and I still have problems with them. In fact, it was once of the first signs pointing the doctor to RA.
Andrew
I have to laugh, too or else I’ll cry.
But, I swear it’s all true.
WP has not been a breeze, but I’ll get there.
Sometime my pats. say: I forgot, you aren’t interested in my ankles & I always reply: I’m interested but later, that is after DAS.
I believe that there’s continuous damage, ever after stopping inflammation, if there is already structural damage. That’s running like an accelerated osteoarthritis — but I don’t have the means to verify this hypothesis.
Have a look at http://rheumatologe.blogspot.com as I show, which activity indices I use.
Dr. Kirsch,
That is so funny. The first part, I mean.
If we (the doctors, researchers, the drug companies, everyone!) do not listen to the patients’ description of their condition, how would we ever find the answers and a cure?
Yes, we need to address inflammation, but you are correct. There is more going on even when inflammation appears to subside.
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Interesting, but why would any RA specialist not include ankles and feet when discussing RA? That is an insane concept. Also, I have had joint pain with an ESR of only 28, with little swelling. My joints feel like they are slightly sprained. The extremely severe pain happens at a higher level, but try walking around for any length of time feeling like your joints are slightly sprained. That can wear on a person as well.
It’s all kind of strange from the patient viewpoint. I know they sometimes laugh about it, assuming all doctors treat all joints anyway, but it’s hard to reconcile that so many important joints are left out specifically or under-valued in the diagnosis criteria as well. Read more on the ACR site here.
Should we count feet in? LOL! My RA started in the mid-foot, and I had erosions and deformity by the time the doc figured out why my feet had been so sore for 18 months. Oh, but my fingers and toes are just fine!
I can surely attest to feet bearing highly important functional roles!
I don’t understand this. Why would ankles and feet be left out? My feet are consistently the worst symptom I have. They were the first symptom I had and were the reason I began seeing doctors that led me to an RA diagnosis. I have days where I can barely walk. In my own mind, I won’t be “better” until my foot pain is gone. Why on earth would my number one symptom not be considered in a DAS?
What is the difference between burned out and remittiuon?
My burned out hands don’t always hit the right keys.
Remission
I’m new to this thread and as it happens having quite the uncomfortable day if you get my drift AND I’m laughing my head off!
We RAers are Hysterical in the face of some really dumb guidelines.
I type this wearing wrist splints on my sofa with my feet which are FLARING.?