Progression continues even during RA remission

[Guest guest]

Rheumawire

Feb 9, 2004

Progression continues even during RA remission

Amsterdam, the Netherlands - Clinical remission is seen as the key to

preventing joint destruction in rheumatoid arthritis (RA), but a new

study by Dutch researchers shows that, in a significant number of

patients, even documented clinical remission is not a reliable indicator

of disease quiescence [1]. Clinically significant joint damage

progression occurred in 15% of RA patients in persistent remission

examined radiologically by Drs Esmeralda TH Molenaar, andre E

Voskuyl (University Medical Center, Amsterdam), and colleagues over a

2-year period. The study is reported in the January issue of Arthritis &

Rheumatism, and the investigators say their work " 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. "

The study included 187 RA patients in clinical remission who were

followed up clinically and radiologically for 2 years. Remission was

defined using a modification of American College of Rheumatology

criteria (omitting fatigue, which had not been uniformly included in the

regular patient assessments). Joint damage was assayed by the Sharp/van

der Heijde method. Patients were required to have been in remission for

6 months before study entry and were allowed to take disease-modifying

antirheumatic drugs (DMARDs) and nonsteroidal anti-inflammatory drugs

(NSAIDs). Patients taking glucocorticoids were excluded.

Patients were assessed every 3 months for exacerbation, which was

defined as no longer meeting the criteria for clinical remission or as

having a DMARD therapy change by the treating rheumatologists because of

worsening of arthritis activity.

Remission persisted throughout the study period in 52% of patients who

met the ACR criteria for remission at baseline and in 42% of those who

had Disease Activity Scale (DAS) of <1.6 at entry, but median radiologic

score for the total group increased from 21 at baseline to 25 after 2

years (p<0.001). As might be expected, clinically significant radiologic

progression (change in the Sharp/van der Heijde score of >5) was more

common in patients who had exacerbations than in those in remission (23%

vs 7%, p=0.001), but Voskuyl tells rheumawire that radiologic

progression, as shown by development of an erosion in a previously

unaffected joint, was observed in about 15% of the patients who remained

in clinical remission.

" These findings suggest that joint destruction may (in part) occur

independently of the presence of synovitis, " Voskuyl says. " Radiologic

progression can occur during a state of persistent remission as defined

by our remission criteria but also as defined by the ACR and DAS

criteria. "

Voskuyl advises monitoring patients in remission every 3 months and

intervening quickly. " Even low disease activity must be treated

vigorously to retard progression of joint damage or development of new

erosions. This is because progressive joint damage is related to

functional performance, " he says.

This evidence that synovitis and joint destruction occur somewhat

independently adds to previous work showing that levels of bone markers

are increased in RA patients even during remissions and that a reduction

of such bone markers is associated with a reduction in long-term joint

damage, regardless of the levels of clinically apparent disease

activity.

Voskuyl suggests that this means that the definition of remission should

be changed to include structurally as well as clinically inactive

disease. " It remains to be determined which parameter is most useful.

Bone or cartilage markers or joint destruction as determined by imaging

(ie, x-ray of hands and feet) may be helpful and should be investigated

in the future, " Voskuyl says. " Urinary type 2 collagen C-telopeptide

also may be useful for monitoring bone change and is currently being

investigated. "

In an editorial that accompanies the article, Dr R Kirwan (Bristol

Royal Infirmary, UK) says that it " offers further evidence that the link

between inflammation and erosions is not clear-cut " and that possibly

several pathologic processes are " proceeding in parallel in the

rheumatoid joint. "

Kirwan also warns that, in view of this possibility, researchers testing

new therapies should resist " the assumption that the control of

inflammation, even by direct attack on the cells thought responsible,

will result in suppression of erosions. "

Janis

Sources

1. Molenaar ET, Voskuyl AE, Dinant HJ, et al. Progression of radiologic

damage in patients with rheumatoid arthritis in clinical remission.

Arthritis Rheum 2004 Jan; 50(1):36-42.

2. Kirwan JR. The synovium in rheumatoid arthritis: evidence for (at

least) two pathologies. Arthritis Rheum 2004 Jan; 50(1):1-4.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

,

That is very interesting. I had x-rays done of hand and feet around

the time I was diagnosed. Do you know how often should new x-rays be

done? I am writing this down as a topic to discuss at my next rheumy

visit. Do you have a link to this study?

Jennie

> Rheumawire

> Feb 9, 2004

>

>

> Progression continues even during RA remission

>

>

> Amsterdam, the Netherlands - Clinical remission is seen as the key

to

> preventing joint destruction in rheumatoid arthritis (RA), but a new

> study by Dutch researchers shows that, in a significant number of

> patients, even documented clinical remission is not a reliable

indicator

> of disease quiescence [1]. Clinically significant joint damage

> progression occurred in 15% of RA patients in persistent remission

> examined radiologically by Drs Esmeralda TH Molenaar, andre E

> Voskuyl (University Medical Center, Amsterdam), and colleagues over

a

> 2-year period. The study is reported in the January issue of

Arthritis &

> Rheumatism, and the investigators say their work " 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. "

>

> The study included 187 RA patients in clinical remission who were

> followed up clinically and radiologically for 2 years. Remission was

> defined using a modification of American College of Rheumatology

> criteria (omitting fatigue, which had not been uniformly included

in the

> regular patient assessments). Joint damage was assayed by the

Sharp/van

> der Heijde method. Patients were required to have been in remission

for

> 6 months before study entry and were allowed to take disease-

modifying

> antirheumatic drugs (DMARDs) and nonsteroidal anti-inflammatory

drugs

> (NSAIDs). Patients taking glucocorticoids were excluded.

>

> Patients were assessed every 3 months for exacerbation, which was

> defined as no longer meeting the criteria for clinical remission or

as

> having a DMARD therapy change by the treating rheumatologists

because of

> worsening of arthritis activity.

>

> Remission persisted throughout the study period in 52% of patients

who

> met the ACR criteria for remission at baseline and in 42% of those

who

> had Disease Activity Scale (DAS) of <1.6 at entry, but median

radiologic

> score for the total group increased from 21 at baseline to 25 after

2

> years (p<0.001). As might be expected, clinically significant

radiologic

> progression (change in the Sharp/van der Heijde score of >5) was

more

> common in patients who had exacerbations than in those in remission

(23%

> vs 7%, p=0.001), but Voskuyl tells rheumawire that radiologic

> progression, as shown by development of an erosion in a previously

> unaffected joint, was observed in about 15% of the patients who

remained

> in clinical remission.

>

> " These findings suggest that joint destruction may (in part) occur

> independently of the presence of synovitis, " Voskuyl

says. " Radiologic

> progression can occur during a state of persistent remission as

defined

> by our remission criteria but also as defined by the ACR and DAS

> criteria. "

>

> Voskuyl advises monitoring patients in remission every 3 months and

> intervening quickly. " Even low disease activity must be treated

> vigorously to retard progression of joint damage or development of

new

> erosions. This is because progressive joint damage is related to

> functional performance, " he says.

>

> This evidence that synovitis and joint destruction occur somewhat

> independently adds to previous work showing that levels of bone

markers

> are increased in RA patients even during remissions and that a

reduction

> of such bone markers is associated with a reduction in long-term

joint

> damage, regardless of the levels of clinically apparent disease

> activity.

>

> Voskuyl suggests that this means that the definition of remission

should

> be changed to include structurally as well as clinically inactive

> disease. " It remains to be determined which parameter is most

useful.

> Bone or cartilage markers or joint destruction as determined by

imaging

> (ie, x-ray of hands and feet) may be helpful and should be

investigated

> in the future, " Voskuyl says. " Urinary type 2 collagen C-telopeptide

> also may be useful for monitoring bone change and is currently being

> investigated. "

>

> In an editorial that accompanies the article, Dr R Kirwan

(Bristol

> Royal Infirmary, UK) says that it " offers further evidence that the

link

> between inflammation and erosions is not clear-cut " and that

possibly

> several pathologic processes are " proceeding in parallel in the

> rheumatoid joint. "

>

> Kirwan also warns that, in view of this possibility, researchers

testing

> new therapies should resist " the assumption that the control of

> inflammation, even by direct attack on the cells thought

responsible,

> will result in suppression of erosions. "

>

> Janis

>

> Sources

>

> 1. Molenaar ET, Voskuyl AE, Dinant HJ, et al. Progression of

radiologic

> damage in patients with rheumatoid arthritis in clinical remission.

> Arthritis Rheum 2004 Jan; 50(1):36-42.

>

> 2. Kirwan JR. The synovium in rheumatoid arthritis: evidence for (at

> least) two pathologies. Arthritis Rheum 2004 Jan; 50(1):1-4.

>

>

>

>

>

> I'll tell you where to go!

>

> Mayo Clinic in Rochester

> http://www.mayoclinic.org/rochester

>

> s Hopkins Medicine

> http://www.hopkinsmedicine.org

[Guest guest]

Jennie, the best I can do is give you the link to the abstract. To view

the full text requires a subscription, and I don't have one to that

journal. Perhaps your rheumatologist does.

Arthritis & Rheumatism

Volume 50, Issue 1 , Pages 36 - 42

" Progression of radiologic damage in patients with rheumatoid arthritis

in clinical remission " :

http://www3.interscience.wiley.com/cgi-bin/abstract/106600984/ABSTRACT

How often X-rays are done is highly dependent on the individual

rheumatologist and the disease characteristics of the patient in

question.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[ ] Re: Progression continues even during RA remission

> ,

>

> That is very interesting. I had x-rays done of hand and feet around

> the time I was diagnosed. Do you know how often should new x-rays be

> done? I am writing this down as a topic to discuss at my next rheumy

> visit. Do you have a link to this study?

>

> Jennie

>

>

> > Rheumawire

> > Feb 9, 2004

> >

> >

> > Progression continues even during RA remission

> >

> >

> > Amsterdam, the Netherlands - Clinical remission is seen as the key

> to

> > preventing joint destruction in rheumatoid arthritis (RA), but a new

> > study by Dutch researchers shows that, in a significant number of

> > patients, even documented clinical remission is not a reliable

> indicator

> > of disease quiescence [1]. Clinically significant joint damage

> > progression occurred in 15% of RA patients in persistent remission

> > examined radiologically by Drs Esmeralda TH Molenaar, andre E

> > Voskuyl (University Medical Center, Amsterdam), and colleagues over

> a

> > 2-year period. The study is reported in the January issue of

> Arthritis &

> > Rheumatism, and the investigators say their work " 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. "

> >

> > The study included 187 RA patients in clinical remission who were

> > followed up clinically and radiologically for 2 years. Remission was

> > defined using a modification of American College of Rheumatology

> > criteria (omitting fatigue, which had not been uniformly included

> in the

> > regular patient assessments). Joint damage was assayed by the

> Sharp/van

> > der Heijde method. Patients were required to have been in remission

> for

> > 6 months before study entry and were allowed to take disease-

> modifying

> > antirheumatic drugs (DMARDs) and nonsteroidal anti-inflammatory

> drugs

> > (NSAIDs). Patients taking glucocorticoids were excluded.

> >

> > Patients were assessed every 3 months for exacerbation, which was

> > defined as no longer meeting the criteria for clinical remission or

> as

> > having a DMARD therapy change by the treating rheumatologists

> because of

> > worsening of arthritis activity.

> >

> > Remission persisted throughout the study period in 52% of patients

> who

> > met the ACR criteria for remission at baseline and in 42% of those

> who

> > had Disease Activity Scale (DAS) of <1.6 at entry, but median

> radiologic

> > score for the total group increased from 21 at baseline to 25 after

> 2

> > years (p<0.001). As might be expected, clinically significant

> radiologic

> > progression (change in the Sharp/van der Heijde score of >5) was

> more

> > common in patients who had exacerbations than in those in remission

> (23%

> > vs 7%, p=0.001), but Voskuyl tells rheumawire that radiologic

> > progression, as shown by development of an erosion in a previously

> > unaffected joint, was observed in about 15% of the patients who

> remained

> > in clinical remission.

> >

> > " These findings suggest that joint destruction may (in part) occur

> > independently of the presence of synovitis, " Voskuyl

> says. " Radiologic

> > progression can occur during a state of persistent remission as

> defined

> > by our remission criteria but also as defined by the ACR and DAS

> > criteria. "

> >

> > Voskuyl advises monitoring patients in remission every 3 months and

> > intervening quickly. " Even low disease activity must be treated

> > vigorously to retard progression of joint damage or development of

> new

> > erosions. This is because progressive joint damage is related to

> > functional performance, " he says.

> >

> > This evidence that synovitis and joint destruction occur somewhat

> > independently adds to previous work showing that levels of bone

> markers

> > are increased in RA patients even during remissions and that a

> reduction

> > of such bone markers is associated with a reduction in long-term

> joint

> > damage, regardless of the levels of clinically apparent disease

> > activity.

> >

> > Voskuyl suggests that this means that the definition of remission

> should

> > be changed to include structurally as well as clinically inactive

> > disease. " It remains to be determined which parameter is most

> useful.

> > Bone or cartilage markers or joint destruction as determined by

> imaging

> > (ie, x-ray of hands and feet) may be helpful and should be

> investigated

> > in the future, " Voskuyl says. " Urinary type 2 collagen C-telopeptide

> > also may be useful for monitoring bone change and is currently being

> > investigated. "

> >

> > In an editorial that accompanies the article, Dr R Kirwan

> (Bristol

> > Royal Infirmary, UK) says that it " offers further evidence that the

> link

> > between inflammation and erosions is not clear-cut " and that

> possibly

> > several pathologic processes are " proceeding in parallel in the

> > rheumatoid joint. "

> >

> > Kirwan also warns that, in view of this possibility, researchers

> testing

> > new therapies should resist " the assumption that the control of

> > inflammation, even by direct attack on the cells thought

> responsible,

> > will result in suppression of erosions. "

> >

> > Janis

> >

> > Sources

> >

> > 1. Molenaar ET, Voskuyl AE, Dinant HJ, et al. Progression of

> radiologic

> > damage in patients with rheumatoid arthritis in clinical remission.

> > Arthritis Rheum 2004 Jan; 50(1):36-42.

> >

> > 2. Kirwan JR. The synovium in rheumatoid arthritis: evidence for (at

> > least) two pathologies. Arthritis Rheum 2004 Jan; 50(1):1-4.