SP0124 WHICH MEASURES TO USE TO ASSESS REMISSION IN RHEUMATOID ARTHRITIS
Authors: Annamaria Iagnocco
Journal: Annals of the Rheumatic Diseases (2019)

<h3></h3> Remission is the ideal target of treatment in rheumatoid arthritis (RA) patients. However, the definition and characterization of remission is still a theme of discussion and its assessment can be a challenging issue in RA clinical practice. Indeed, nonetheless the new treatments and therapeutic strategies for RA make remission possible, sub-clinical inflammation can still be present both at the joint site and at the patient level, leading to damage progression and to occurrence of flares. Clinically, remission entails persistent absence of any sign of joint and systemic inflammation. However, the presence of some residual joint inflammatory activity can be accepted by current clinical indexes such as DAS28, SDAI, CDAI and Boolean remission, although the latter is clearly based on more stringent parameters (1,2). Based on those criteria, and particularly with the use of SDAI and Boolean cut-offs, complete and persistent remission is then quite uncommon in late RA, while it seems to be more easily possible in early disease (3). Another interesting issue to consider in clinical practice is the presence of sustained remission which seems to occur less frequently than remission at different point times and with only a minority of cases reaching a complete disease recovery (4). Depending on the modality that is used, the assessment of remission by imaging encompasses the evaluation of a wide spectrum of lesions. While ultrasound is able to show intra- and peri-articular signs of inflammation and to differentiate active from inactive synovitis with the use of Doppler modes, MR shows also bone marrow inflammatory-related abnormalities. Moreover, ultrasound detects inflammation at multi-site level and allows the measurement of stable remission over time on longitudinal evaluation. Interestingly, also tenosynovial Doppler inflammation has been demonstrated to be a frequent finding in patients in clinical remission and, compared to joint synovitis, it is more associated with self-perceived unstable remission (5). In addition, tenosynovial and joint Doppler positivity has been demonstrated to be an independent risk factor of flare in RA patients in remission (6). Residual joint inflammation in patients in remission can be demonstrated also by other imaging techniques, such as PET which shows enhanced tracer uptake at different joint sites (3). Basically, the capability of imaging to demonstrate sub-clinical disease activity even in patients in clinical remission, by allowing the detection of residual inflammation at different joint sites and at different disease stages gives it an added value compared to clinical assessment alone. In conclusions, clinical evaluation of remission alone appears frequently inadequate to capture a real persistent lack of inflammation at different joint sites. Imaging can complement the assessment of patients in clinical remission, offering additional data that may still reveal a certain amount of sub-clinical disease activity. With new therapeutic strategies RA management has become increasingly complex over the last years (7). The relevance of this information is then substantial, being structural damage the result of both previous and current phases of disease activity. <h3>References:</h3> [1] Felson, et al. Ann Rheum Dis 2011;70: 404–13. [2] Chandrashekara, et al. International Journal of Rheumatic Diseases 2013; 16: 291–6. [3] Bugatti, et al. Front Med (Lausanne)2018; 15: 140-8. [4] Pope, et al. Athritis Care Res (Hoboken) 2019 Mar 1. doi: 10.1002/acr.23862. [5] Bellis, et al. Rheumatology 2016; 55: 1826-36. [6] Filippou, et al. Ann Rheum Dis 2018; 77: 1283-9. [7] Smolen, et al. Ann Rheum Dis 2017; 76: 960-77. <h3>Disclosure of Interests:</h3> None declared