Progression of radiologic damage in patients with rheumatoid arthritis in clinical remission

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Progression of radiologic damage in patients with rheumatoid arthritis in

clinical remission

Esmeralda T. H. Molenaar 1, andre E. Voskuyl 1 *, Huib J. Dinant 2, P.

Dick Bezemer 1, Maarten Boers 1, Ben A. C. Dijkmans 3

1VU University Medical Center, Amsterdam, The Netherlands

2Jan van Breemen Instituut Amsterdam, Amsterdam, The Netherlands

3VU University Medical Center, and Jan van Breemen Instituut, Slotervaart

Ziekenhuis, Amsterdam, The Netherlands

email: andre E. Voskuyl (ae.voskuyl@...)

*Correspondence to andre E. Voskuyl, Department of Rheumatology, VU

University Medical Center, Post Office Box 7057, 1007 MB, Amsterdam, The

Netherlands

Abstract

Objective

To assess whether radiologic progression occurs during clinical remission in

patients with rheumatoid arthritis (RA).

Methods

One hundred eighty-seven patients with RA in clinical remission were

followed up clinically and radiologically for 2 years. Clinical remission

was defined according to a modification of the American College of

Rheumatology criteria (i.e., the criterion of fatigue was omitted, and

patients had to fulfill 4 of the 5 remaining criteria). Radiologic joint

damage was assessed by the Sharp/van der Heijde method.

Results

After 2 years of followup, remission persisted in 52% of patients. The

median radiologic score for the total group of patients increased from 21

(interquartile range [iQR] 5, 65) at the time of entry to 25 (IQR 7, 72)

after 2 years (P < 0.001). The median score for radiologic progression

between baseline and 2 years was 0.5 (IQR 0, 2.5). Among patients with an

exacerbation of RA (n = 86), the median score for progression over 2 years

was 1.0 (IQR 0, 4.5) (P < 0.001), and in patients with a persistent

remission (n = 93) it was 0 (IQR -0.5, 2.0) (P < 0.001). Clinically relevant

progression of damage was more frequent in patients with exacerbation (23%)

than in those with persistent remission (7%) (P = 0.001). However, in 15% of

patients with persistent remission, an erosion developed in a previously

unaffected joint. In the logistic regression analysis, the area under the

curve of the Disease Activity Score, a continuous measure, was related to

the chance of radiologic progression, regardless of the absolute disease

activity level. Results were similar when other definitions of remission

were used.

Conclusion

Although rare, clinically relevant progression of joint damage does occur in

patients with RA in prolonged remission. This suggests the need for markers

that predict progression during periods of low disease activity and for

drugs that prevent damage that is independent of disease activity.

Received: 2 January 2003; Accepted: 13 October 2003