Remission in early rheumatoid arthritis.
OBJECTIVE
We systematically reviewed remission as an outcome measure in observational studies and randomized controlled trials (RCT) in early rheumatoid arthritis (RA). Our objectives were to identify its frequency using different criteria, to determine the influence of different treatment strategies on remission, and to review the effects of remission on radiological outcomes.


METHODS
Pubmed, Medline and Embase were searched using the following terms: Early Rheumatoid Arthritis or Early RA combined with Remission, Treatment, anti-Tumor Necrosis Factor (TNF) or Disease-modifying Antirheumatic Drugs (DMARD). Remissions were reported using American College of Rheumatology (ACR) criteria and Disease Activity Score (DAS) criteria.


RESULTS
Seventeen observational studies (4762 patients) reported remission in 27% of patients, 17% by ACR criteria and 33% by DAS criteria. Twenty RCT (4 comparing DMARD monotherapies, 13 comparing monotherapy with combination therapies, 3 comparing combination therapies) enrolled 4290 patients. ACR remissions occurred in 16% receiving DMARD monotherapy and 24% combination therapies (random effects OR 1.69, 95% CI 1.12-2.36). DAS remissions occurred in 26% and 42%, respectively (OR 2.01, 95% CI 1.46-2.78). Observational studies showed continuing radiological progression despite remission. RCT showed less radiological progression in remission when treated with combination therapy compared to monotherapies.


CONCLUSIONS
Remission is a realistic treatment goal in early RA. Combination therapies using DMARD with or without TNF inhibitors increase remissions. Radiological progression occurred in remission but is reduced by combination therapies. ACR and DAS remission criteria are not directly comparable and standardization is needed.
Department of Rheumatology, GKT School of Medicine, King's College London, London, UK. margaret.ma@nhs.net
Margaret H Y
MH
Ma
Ian C
IC
Scott
Gabrielle H
GH
Kingsley
David L
DL
Scott
D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D016208:Databases, Factual; D006801:Humans; D015201:Meta-Analysis as Topic; D016032:Randomized Controlled Trials as Topic; D012074:Remission Induction; D016896:Treatment Outcome; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors
D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha