Progression continues even during RA remission

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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.

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Mayo Clinic in Rochester

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s Hopkins Medicine

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