Background/Purpose: Remission is widely accepted as the goal of treatment in RA and has to be sustained to keep joint damage at a minimum (Smolen et al 2010). The DAS28<2.6 remission criterion is widely used but criticized for allowing remission to be present in spite of several swollen or tender joints. The recently proposed Boolean ACR/EULAR remission criteria are more stringent and do not have this bias but their utility in long-term observational studies needs to be evaluated. The present study addresses the performance of these criteria over 8 years in an observational study of patients with early RA.

Methods: 839 patients, included in 1992-1999, within one year from disease onset in the BARFOT observational study were followed for 8 years. The following remission criteria (RCr) were applied: The DAS28 RCr (DAS28<2.6) and the ACR/EULAR RCr (≤1 swollen joint, ≤1 tender joint, CRP ≤1 mg/dl and patient global assessment ≤1 (0-10 scale). Sustained remission was defined as remission at all four visits at 1, 2, 5 and 8 years. Radiographic joint damage was assessed by the Sharp van der Heijde method (SHS).

Results: Sustained remission was present in 79 patients (14%) by the DAS28 RCr and 16 (3%) by the ACR/EU RCr. In patients in sustained remission by the DAS28 RCr, radiological progression (RP) with SHS of >0 occurred in 31, 45, 57 and 65% and by the ACR/EU RCr in 21, 46, 46 and 62% at 1, 2, 5 and 8 years, respectively. The likelihood ratios for the ability of sustained remission by the the DAS28 criteria and the ACR/EU criteria, respectively, to identify patients with favorable radiographic outcome from baseline to 8 years was 2.2 vs 1.9 for a change in SHS of ≤0 (minimal RP), 1.5 vs 1.4 for a change of <5 (clinically relevant change) and 1.4 vs 1.3 for a change of <8 (<1 point per year). A small number of patients in sustained remission by DAS28 RCr had at some point in time more than one swollen or tender joint. More than one joint was found in 11 of 315 assessments (3.5%) of tender joint count (max 5 in one case) and in 28 of 315 assessments (9%) of swollen joint count (max. 6 in one case).

Conclusion: The new ACR/EU criteria appear too stringent to be feasible in long-term observational studies. Only a very small number of patients were identified and the ability to predict favorable radiographic outcome was not significantly superior. Sustained remission by the DAS28 criteria was more than four times as frequent and the frequency of possible false remissions was very low. Therefore, awaiting further development, the DAS28 remission criterion could be preferred in long-term observational studies.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/performance-of-criteria-for-remission-in-a-long-term-observational-study-of-patients-with-early-rheumatoid-arthritis/