If patients have disease activity scores that indicate low levels of inflammation and few affected joints, but are still experiencing pain, this could indicate other diseases such as fibromyalgia or osteoarthritis. Domingues explains. This is the biggest misconception Dr. Domingues hears about remission. These diseases are like a roller coaster, says Dr. If you go into remission, you may want to see if you can change your medication regimen to lower your dosages or take fewer medications — or see if you can stop taking medication altogether, even if temporarily.
But whether you can actually remain in remission while tapering or stopping medication is something rheumatologists are actively studying. Stopping medication not only means risking that you could fall out of remission and experience pain and other arthritis symptoms, but also means that the same medications might not work as well if you need to restart them in the future.
Being in remission means less inflammation throughout the whole body, which can have protective effects on other organs, such as your heart. Rheumatoid arthritis raises your risk for heart disease and heart attacks, but achieving and sustaining remission can help lower such risks.
RA and other inflammatory arthritis can also cause permanent joint damage when inflammation remains high. While the right medication plan is often the most important part of getting to and staying in remission, other factors can play a role as well. A study presented at the annual meeting of the American College of Rheumatology in found that for women, being obese more than doubled the risk of not achieving remission within 12 months.
For men, current smokers were 3. Stress may play a role too, says Dr. Domingues, who advises trying to be aware of your stress levels and when they feel out of control for you. Tags: Rheumatoid Arthritis. CreakyJoints is a digital community for millions of arthritis patients and caregivers worldwide who seek education, support, advocacy, and patient-centered research.
We present patients through our popular social media channels, our website CreakyJoints. We represent patients through our popular social media channels, our website CreakyJoints. Only fill in if you are not human. Doctors and patients together determine when a patient has achieved remission Doctors have different ways to evaluate whether your disease is in remission. The most often applied time to define sustained remission before tapering or withdrawing of treatment is 6 months.
The greatest loss of remission status occurs after a single remission visit, and once remission is seen on two subsequent visits, the chance of remaining in remission becomes much higher.
The maintenance of remission the first years after that remission had been achieved, were similar for seropositive and seronegative patients in this study.
These results suggest that the prognosis of the disease course in both seropositive and seronegative RA may be defined by the efficacy of therapeutic interventions applied the first years after diagnosis. Thirdly, the reported rates of sustained remission range depending on the choice of remission criteria, treatment regimen and RA patient population. The highest rates of sustained remission could likely be achieved in early RA patients receiving early intensive therapy.
Application of the stringent remission criteria likely differentiates a particular subgroup of patients with a particular favorable functional status. The DAS remission criterion has been criticized for allowing classification of patients as being in remission in spite of having several swollen joints, not compatible with a state of remission.
The low frequency of sustained remission by these criteria suggests that they may be too stringent to suite for long-term observational studies.
In clinical practice, it seems reasonable and feasible to use the DAS-based remission criteria for the definition of sustained remission. On the contrary, treatment-induced remission would occur at different rates with explicitly different treatments. Therefore, with earlier and intensive treatment strategies, higher overall remission rates and higher rates of sustained remission as well as sustainability of remission for a longer time are expected.
Indeed, evidence supporting the concept of modifiable achievement of drug-free remission is expanding. With early treatment and improved therapeutic strategies the last decade, sustained remission is not uncommon anymore.
Altogether, early rapid and sustained suppression of disease activity the first year guided by criteria of low disease activity may provide sustained remission and therapy de-escalation. The somewhat low rate of regained remission in this study could depend on inclusion of patients with a high risk of developing persistent arthritis and that therapy was steered by criteria of low disease activity.
Of these, 11 and 7 patients remained in drug-free remission for at least 3 and 6 months, respectively. The benefits of early intensive treatment with tocilizumab TCZ compared with methotrexate monotherapy to achieve sustained remission have been demonstrated in the U-Act-Early randomized clinical trial. If sustained remission was achieved, the dose of all drugs was stepwise reduced and then discontinued, provided that sustained remission persisted.
This study therefore suggested that rates of early sustained remission are different in patients depending on the previous treatment strategies. Thus, in the Productivity and Remission in a randomIZed controlled trial of etanercept in Early rheumatoid arthritis PRIZE study, one of four patients who were in DAS28 remission induced by early initial treatment with etanercept and MTX were still in remission more than 1 year after the cessation of both drugs.
Although suggesting that drug-free remission could be modified by treatments, the follow up of both the U-Act-Early study and the RCT studies are too short to prove the hypothesis that drug-free remission can be induced by a certain drug or a certain treatment strategy.
The patient perception of remission was examined in the inductive thematic analysis of the prespecified guided focus group discussions with RA patients in Austria, The Netherlands and UK.
Achievement of DMARD-free remission at any timepoint in the disease course in the EAC cohort was related to better outcomes compared with outcomes among patients who did not achieve such remission.
Importantly, better outcomes were demonstrated in all patients who achieved remission, irrespective whether remission was achieved early within 3 years after inclusion , intermediate 3—5 years of disease or late 5—13 years after RA diagnosis. This finding implies that resolution of arthritis is possible and not limited to early disease but indeed can occur even in longstanding disease. Whether standard disease measures are not sensitive to measure the differences of remission achieved in different stages of disease, and whether pathophysiological mechanisms of transition from chronic inflammatory state to DMARD-free sustained remission may differ in different stages of RA can only be speculated on.
RA is a fluctuating disease with fluctuating disease activity over time. Overall disease activity is a risk factor for radiographic progression, loss of function and early mortality.
The state of sustained remission should ideally indicate absence of disease activity and thence a halt of further joint damage.
Indeed, in patients with established RA treated in usual care, physical function measured by HAQ improved in patients reaching DASsustained remission for at least 6 months at two consecutive visits compared with patients who only occasionally reached remission; and the HAQ continued to improve while in sustained remission.
The likelihood of experiencing active disease decreases as duration in remission increases, which is reassuring for systematical treatment tapering in patient with sustained remission.
However, even after the loss of remission at follow up, sustained remission in the course of the disease may be beneficial in respect to long-term clinical outcomes. Further, once sustained remission is achieved, a chance to regain remission after flare is high. The percentage of patients who regained remission after a flare was low in this cohort, likely because of the long disease duration a median of 8 years and 1-year interval between visits.
Sustained absence of disease activity also suggests a halt of functional deterioration and normalized survival. Remission according to less stringent criteria based on the and joint counts showed a weaker protection against future disability.
Patients who were in remission 1 year after the baseline assessments and had persistent remission over time had the greatest reduction in mortality risk compared with patients who never achieved remission within the first 3 years of follow up, HR 0.
Remission according to less stringent definitions was associated with progressively lower beneficial effect for overall survival. The relation between sustained remission and survival outcome has been studied in patients with early RA or undifferentiated arthritis UA included in the Leiden EAC cohort between and Patients who achieved DMARD-free sustained remission within 3 years had a reduced mortality compared with patients without remission, HR 0.
The concept of improved long-term outcomes achieved by targeted treatment strategies has been also demonstrated in the BeSt study in patients with early RA. Altogether these observations imply that sustained remission is a desirable outcome relevant from the patient perspective and associates with a halt of joint damage progression, improved function and survival prognosis. Sustained drug-free remission reflects normalized health state and survival expectations close to these in the general population.
The importance to treat early and to treat-to-target in early RA is supported by results of several studies. Further, in the Dutch study from the Nijmegen early RA cohort, the median time to sustained remission was 10 months in the subcohort included between — and 14 months in the subcohort included between — The chance on sustained remission decreased with every additional month of time-to-remission.
The relationship between time-to-remission and sustained remission was similar across all calendar years of inclusion in this study, —, —, —, — This observation implies the importance of achieving remission with any treatment strategy as early as possible in the course of the disease.
Next, the data from the BeST trial of treat-to-target treatment strategies in patients with recent-onset RA have demonstrated that the longer and the better a good clinical state is maintained, the greater the likelihood of remaining in that state.
The importance of early and intensified antirheumatic therapy in achievement of drug-free sustained remission has been demonstrated in the Leiden EAC cohort. From this cohort we have learned that achievement of DMARD-free sustained remission is increased in the recent years of early improved antirheumatic strategies. The time to achieve DMARD-free remission was shown to be shorter and the prevalence of remission higher in the patients included the last years than in those included in the s.
The concept of RA disease course and outcomes with the development of treatment strategies is presented in figure 1. The concept of rheumatoid arthritis disease course and outcomes with the development of treatment strategies. The treatment steered at the treatment target of remission is important in order to improve chance on achievement of early remission and drug-free remission.
Patients who did not achieve early DAS remission were randomized to MTX plus hydroxychloroquine plus sulfasalazine plus low dose prednisone arm 1 , or to MTX plus adalimumab arm 2. The frequency of drug-free remission did not differ between the treatment arms. Radiographic outcome was excellent for all patients, median IQR SHS progression was 0 0—0 across all patients in this study. In short, initial targeted intensive treatments and early remission seem to be essential to achieve sustained remission and hence essential to modify the course of RA disease.
Sustained remission is associated with improved long-term outcomes as measured by function, patient-reported outcomes and survival. With therapeutic strategies targeted at a low disease activity sustained remission can be achieved in many patients. Sustained remission is achievable in patients with both early and established disease. Sustained remission means suppressed disease activity in the patients who may flare during follow up.
Disease activity should be monitored and therapy should be adjusted during the whole disease course. In a proportion of patients, sustained remission means re-establishment of immune tolerance.
Drug-free remission is characterized by normalization of function and general health status. Early therapy targeted at remission is likely to improve the chance to achieve drug-free remission. The efficacy of therapies alters along the disease course and potential reversibility of autoimmunity in RA seems to decrease over time. In future, with understanding of pathways behind initiation and perturbation of immune regulation, new targeted interventions at an individual patient level would influence mechanisms driving occurrence of sustained drug-free remission, and hopefully, could offer a cure.
National Center for Biotechnology Information , U. Ther Adv Musculoskelet Dis. Published online Aug 2. Sofia Ajeganova and Tom Huizinga. Author information Article notes Copyright and License information Disclaimer. Email: ln. Received Apr 18; Accepted Jun This article has been cited by other articles in PMC. Abstract Sustained remission is an ultimate treatment goal in the management of patients with rheumatoid arthritis RA.
Keywords: rheumatoid arthritis, sustained remission, drug-free remission, treatment strategy, outcome, disability. Other people might better initially aim for low disease activity as an initial target, but once that is reached, remission may be the next logical step. People who achieve sustained remission can go about their lives in a state of near normality, with less pain and fatigue than those with more active disease, according to a review of research published in Therapeutic Advances in Musculoskeletal Disease in August In addition, the reviewers found that those who achieved remission at any point in the course of their disease had better long-term outcomes than others — regardless of whether that remission happened soon after diagnosis or many years later.
When people with RA were asked questions before they started a new DMARD and then evaluated later for physical improvements, more than 10 percent of their treatment response could be attributed to their earlier expectation that the drug would be effective, according to a study published in Therapeutic Advances in Musculoskeletal Disease in May One of the most commonly used tools is the disease activity score known as DAS This assessment measures:.
According to the criteria, a DAS score less than 2. As researchers noted in a letter to the British Medical Journal published in May , there are several shortcomings to this approach: Joints in the feet are not included in the count, and patients sometimes self-rate their disease as high because they also suffer from osteoarthritis or another coexisting condition. Importantly, imaging like ultrasound or MRI are not used to confirm whether even low levels of joint inflammation remain. This approach is where a doctor and patient agree up front on what the treatment goal is, then regularly test to see if that goal is being met and adjust medicines accordingly if it has not.
It has resulted in a higher rate of remission, as well as improved mobility over time and less damage to the joints. The most important factor in rheumatoid arthritis remission is early and aggressive treatment with medication that improves or alleviates symptoms and halts the progression of the disease, experts say.
Because RA is a systemic inflammatory disease, it can affect all body systems, not just joints. When untreated or undertreated, RA puts patients at higher risk for developing coronary artery disease , stroke, and other cardiovascular disease compared with those whose disease is in remission. While even well-treated people with RA have higher cardiovascular risk both because of the disease and medication side effects, tight RA control substantially improves CV risk, experts say.
Effective treatment reduces chronic inflammation and reduces the need for high doses of steroids and nonsteroidal anti-inflammatory drugs NSAIDs , Dr.
Blazer says, noting that both of these can raise cardiovascular risk. Although RA drugs do have side effects, the repercussions of the disease, including permanent joint damage, are generally much worse than the side effects associated with the medications, experts say. Because rheumatoid arthritis is a disease of an overactive immune system, many drugs used to treat it suppress the immune system.
This drug improves pain and inflammation and also helps slow the progression of arthritis. If methotrexate is not sufficient, after a time doctors should consider adding a biologic.
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