What is the definition of remission in RA?

1
What is the definition of remission in RA?

• American Rheumatism Association (ARA)¹
• Five or more of the following criteria must be
  fulfilled for at least two consecutive months
• Duration of morning stiffness not exceeding 15
  minutes
• No fatigue
• No joint pain (by history)
• No joint tenderness or pain on motion
• ESR (Westergren method) Female lt 30 mm/h,
  Male lt 20 mm/h
• DAS44² lt1.6
• DAS28² lt2.6
• CDAI³ lt 2.8

1.Pinals RS, et al. Arthritis Rheum.
1981241308-15. 2. Prevoo. Br J Rheumatol.
1996351101-5. 3. Aletaha D, et al Arthritis Res
Ther. 20057R796-R806
2
Remission in rheumatoid arthritis

• Criteria for clinical remission
• Remission LDA
• Modified ACR criteria 4/5 (pain, TJ, SJ,
  MS,ESR)
• DAS 1.6 2.4
• DAS28 2.6 3.2
• SDAI (SJTJPGACRP) 3.3 11
• CDAI (SJTJPGA) 2.8 10
• Sustained remission
• Imaging remission
• MRI, US
• Complete clinical response (FDA)
• remission 6 months radiographic
  arrest

3
Remission is Heterogenous

• Clinical Remission ACR/DAS criteria, or normal
  acute phase response, no clinical synovitis
• Imaging Remission no significant synovitis on
  sensitive imaging
• True Remission a state of no detectable disease
  with no progression of structural damage

4
Radiographic progression Improvement with TNF
Targeted Therapies (TEMPO)
Total sharp score change over 3 years
6
MTX
ETN
ETN MTX
4
Change from baseline (mean SD)

2


0



-2
0
1
2
3
Years
Plt0.05 ETN vs MTX, combo vs MTX combo vs ETN
van der Heijde, et al. Ann Rheum Dis
200665(Suppl. II)509
5
TEMPO extension study DAS28 remission
ETN MTX Combination (n96)
15
MTX add ETN (n55)
ETN add MTX (n76)
64 (plt0.05)
47
56 (plt0.05)
42
41
40
25
26
Martin Mola E et al. Presented at EULAR 2007.
FRI0148.
6
BeSt Treatment Strategies
Sequential monotherapy n126 Step-up combination n121 Initial combination with prednisone n133 Initial combination with infliximab n 128
7
Percentage in remission in BeSt
De Vries Bouwstra Ann Intern Med 2007 146
406-15.
8
Results Summary

• At 5 years
• 48 of patients in DAS remission
• 10 - 19 of patients in drug-free remission
• 51 patients previously in drug-free remission had
  restarted a DMARD

Klarenbeek et al. Ann Rheum Dis 200867(Suppl
II)187