VIENNA, Austria—Joint damage that can be seen on radiography stops worsening after rheumatoid arthritis (RA) is brought into remission, but the “carry over” effect of past inflammation means the joints won't stabilize fully until RA remission has been sustained for 6 to 9 months. This lag-time should be taken into account by clinicians and researchers monitoring RA progression, Daniel Aletaha, MD, and colleagues report in Arthritis & Rheumatism.¹

”These data indicate that the level of disease activity as well as the duration of remission affect subsequent progression of radiographic damage in RA. This latency between disease activity and its effects on radiographic progression should be considered when evaluating radiographic outcomes in trials of RA,” Dr. Aletaha said. He is in the Division of Rheumatology at the Medical University of Vienna, Austria.

Close look at PREMIER trial data reveals delay between remission and radiographic gains

Dr. Aletaha and colleagues report a post hoc analysis of data from the PREMIER study, a 2-year randomized, controlled clinical trial of adalimumab (Humira^®) plus methotrexate versus methotrexate alone or adalimumab alone in early RA. The objective of this analysis was to determine “whether joint damage can be generally arrested in states of sustained remission.”

The answer is “yes”—but only after RA disease activity has been pounded down below detectable levels for a long enough time.

The researchers found that although there was “a virtual arrest of progression of radiographic scores at the group level in patients who maintained remission between month 12 and month 24” in all 3 treatment groups, some patients in each group had radiographic scores even though they were in clinical remission throughout the second year. Dr. Aletaha found that most of these patients had attained remission 3 months or less before the year 1 radiograph was taken.

“In contrast, in 80% of patients who had already achieved remission for 9 months before the first radiograph was assessed, joint destruction did not progress, and in the remainder of patients, maximal progression was numerically lower than that in those with shorter periods of remission. Therefore, joint damage in RA does not progress in states of sustained remission in the majority of patients,” Dr. Aletaha said.

RA remission and joint damage: Translating research into practice

The investigators conclude that, regardless of the type of treatment used, sustained remission of RA is associated with a halt in joint damage. Some progression may occur in patients who have been in remission for only a short time, “and this is likely a consequence of a carry-over effect of past periods of inflammation,” they write.

They advise, “in the process of therapeutic decision-making, the assessment of radiographic progression of joint damage will have to account for these observations regarding the latency of radiographic manifestation in patients with RA.”

Reference

1. Aletaha D, Funovits J, Breedveld FC, et al. Rheumatoid arthritis joint progression in sustained remission is determined by disease activity levels preceding the period of radiographic assessment. Arthritis Rheum. 2009;60:1242-1249.