Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice-Based Call for a Paradigm Change

Ferreira, Ricardo J.O.; da Silva, J. A.P.; Duarte, C�tia; Ndosi, Mwidimi; de Wit, Maarten; Gossec, Laure

Abstract

© 2017, American College of Rheumatology Objective: In current management paradigms of rheumatoid arthritis (RA), patient global assessment (PGA) is crucial to decide whether a patient has attained remission (target) or needs reinforced therapy. We investigated whether the clinical and psychological determinants of PGA are appropriate to support this important role. Methods: This was a cross-sectional, single-center study including consecutive ambulatory RA patients. Data collection comprised swollen 28-joint count (SJC28), tender 28-joint count (TJC28), C-reactive protein (CRP) level, PGA, pain, fatigue, function, anxiety, depression, happiness, personality traits, and comorbidities. Remission was categorized using American College of Rheumatology/European League Against Rheumatism Boolean-based criteria: remission, near-remission (only PGA >1), and nonremission. A binary definition without PGA (3v-remission) was also studied. Univariable and multivariable analyses were used to identify explanatory variables of PGA in each remission state. Results: A total of 309 patients were included (remission 9.4%, near-remission 37.2%, and nonremission 53.4%). Patients in near-remission were indistinguishable from remission regarding disease activity, but described a disease impact similar to those in nonremission. In multivariable analyses, PGA in near-remission was explained (R2adjusted = 0.50) by fatigue, pain, anxiety, and function. Fatigue and pain had no relationship with disease activity measures. Conclusion: In RA, a consensually acceptable level of disease activity (SJC28, TJC28, and CRP level ≤1) does not equate to low disease impact: a large proportion of these patients are considered in nonremission solely due to PGA. PGA mainly reflects fatigue, pain, function, and psychological domains, which are inadequate to define the target for immunosuppressive therapy. This consideration suggests that clinical practice should be guided by 2 separate remission targets: inflammation (3v-remission) and disease impact.

• Journal Article Type: Article
• Acceptance Date: May 16, 2017
• Online Publication Date: May 23, 2017
• Publication Date: Mar 1, 2018
• Deposit Date: May 11, 2017
• Publicly Available Date: May 23, 2018
• Journal: Arthritis Care and Research
• Print ISSN: 2151-464X
• Electronic ISSN: 2151-4658
• Publisher: Wiley
• Peer Reviewed: Peer Reviewed
• Volume: 70
• Issue: 3
• Pages: 369-378
• DOI: https://doi.org/10.1002/acr.23284
• Keywords: arthritis, inflammation
• Public URL: https://uwe-repository.worktribe.com/output/888337
• Publisher URL: http://dx.doi.org/10.1002/acr.23284
• Additional Information: Additional Information : This is the peer reviewed version of the following article: Ferreira, R. J., Duarte, Cátia, Ndosi, M., de Wit, M., Gossec, L. and da Silva, J. (2017) Suppressing inflammation in rheumatoid arthritis: Does patient global assessment blur the target? A practice–based call for a paradigm change. Arthritis Care and Research. ISSN 2151-4658 [In Press] Available from: http://eprints.uwe.ac.uk/31585, which has been published in final form at http://dx.doi.org/10.1002/acr.23284. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.
• Contract Date: May 12, 2017