RA remission criteria expanded

3 minute read

The recently approved 2022 ACR/EULAR RA remission criteria have a higher patient global assessment threshold, meaning more patients achieve remission.

The 2011 provisional ACR/EULAR RA remission criteria have been revised.

The latest criteria, approved by the ACR board of directors and EULAR executive committee, mean more patients could be classified as achieving remission.

The key change was to the patient global assessment component of the criteria, scored on a 0-10cm scale. It was argued that the required score of ≤1cm was difficult to achieve, even in the absence of swollen and tender joints and with favourable CRP levels.

By way of background, RA disease activity was defined in the 1990s by several core set variables: tender joint count and swollen joint count; patient assessment of global disease activity and pain; physician global assessment; a measure of function such as the health assessment questionnaire; and acute-phase reactant such as C-reactive protein.

Based on these variables, there were two types of remission definitions agreed on by ACR and EULAR for the 2011 provisional remission criteria. The Boolean definition required swollen and tender joint counts, patient global assessment and CRP (in mg/dL) to have a value of ≤1. The index-based definition of remission was based on the simplified disease activity index.

With remission now a realistic therapeutic target, the 2022 revision came about amid concerns that the 2011 RA remission criteria was too stringent, allowing few patients to achieve remission and potentially resulting in overtreatment. Also, there was also only moderate agreement between the Boolean and index definitions, largely due to the patient global assessment.

The authors noted that “the definition of remission should remain strict and ensure beneficial long-term outcomes for patients with RA and prevent unnecessary treatment escalation at the same time.”

Thus, a higher threshold of ≤2cm was proposed and tested, which the authors reported “increases the agreement with index-based remission criteria without jeopardizing predictive value for radiographic or functional outcomes”.

The next step, outlined in papers simultaneously published in Arthritis & Rheumatology and the Annals of the Rheumatic Diseases, was to externally validate the revised criteria. Datasets from four clinical trials of biologics were used and included over 2000 participants with early or established RA.

Using the 2cm threshold for patient global assessment meant 14% achieved remission, compared with 10% of patients using the 1cm threshold.

“We validated the results of the performance of the Boolean2.0 and the provisionally endorsed index-based remission definitions [and] propose that these revised ACR/EULAR remission criteria be adopted both for future clinical trials and as a target in clinical practice,” wrote the authors.

The authors suggested extending the study of the revised criteria to include other DMARDs, such as JAK inhibitors, and to include patients from other countries and ethnic groups.

Arthritis rheumatol 2022, online 23 October

Ann Rheum Dis 2022, online 24 October

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