MONTPELLIER, France—Joint damage continues to worsen in nearly 17% of early rheumatoid arthritis (RA) patients who have been in clinical remission for up to 5 years, Gregory Cohen, MD, and colleagues report in the March issue of Annals of the Rheumatic Diseases.¹ This radiologic damage seems to be independent of joint inflammation and should become part of the remission criteria in RA, the study authors suggest.

"These data suggest that radiographic damage may be partly independent of clinical joint inflammation, and that regular monitoring of radiographic damage in patients with early RA should be mandatory in addition to frequent disease activity measurement, as was previously recommended," writes lead author Gregory Cohen, MD, at Centre Hospitalier Universitaire Lapeyronie, in Montpellier, France.

Patients had early RA in sustained remission

The researchers began with a cohort of 191 patients with active early (<1 year) RA, of whom 57 patients died or were lost to follow-up or had incomplete data.

Study patients were assessed at baseline, 3 years, and 5 years using the Disease Activity Score (DAS) and the Sharp-van der Heijde Score for radiographic damage (SHS). Patients in remission, as defined by a DAS <1.6 at the 3-year and 5-year time points (n = 30), were compared with patients with a persistently active RA (n = 104) using Wilcoxon's signed rank test.  Radiographic progression was defined as an increase of more than 4.1 points on the SHS.

The researchers found that radiographic progression over 5 years was somewhat lower in the 30 patients who remained in remission at 3 and 5 years than in the 104 patients who continued to have active disease (P = .0047).

The median SHS score increased from .5 (0-7) at baseline to 2.5 (0-14) after 5 years for the remission group (P = .18, no significant change from baseline) and from 2 (0-7) to 13 (3-29) in the active disease group (P <.001), the study found. However, 10 of the 30 patients in sustained remission (30%) at 3 and 5 years had a significant increase in radiographic damage (SHS change of 4.1 or greater), five patients in remission (16.7%) had significant progression of damage between the 3- and 5-year assessment, and six (20%) presented new erosions in a previously unaffected joint between the 3- and 5-year assessment.

Absence of progression should be part of the remission definition in RA

"Our data showed that remission based on the DAS criteria is a clinically relevant goal for management of early rheumatoid arthritis despite the fact that mild radiographic progression may occur in some patients," the researchers write. They call for the evaluation of magnetic resonance imagine (MRI) and ultrasonography to evaluate nondetectable clinical joint inflammation in patients whose RA is in remission "even though further studies are needed to decide what degree of radiological progression in patients in clinical remission may be relevant for long-term outcomes."

Other rheumatology specialists agree. "The presence of radiological progressions should be part of remission criteria in RA because, as this article and many recent studies have demonstrated, there is a disconnect between controlling symptoms and signs (which most remission criteria are based on) and stopping radiographic progression," Arthur Weaver, MD, clinical professor of medicine at the University of Nebraska Medical Center, in Omaha, told CIAOMed. "One should obtain x-rays (possibly ultrasound or MRI) on a regular basis to determine radiographic progression or the lack of such."

Reference

1. Cohen G, Gossec L, Dougados M, et al. Radiological damage in patients with rheumatoid arthritis on sustained remission. Ann Rheum Dis. 2007;66:358-363.