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Phrasing of the patient global assessment in the rheumatoid arthritis ACR/EULAR remission criteria: an analysis of 967 patients from two databases of early and established rheumatoid arthritis patients

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Abstract

The ACR/EULAR Boolean remission criteria for rheumatoid arthritis (RA) include a strict cutoff for patient global assessment (PGA, value ≤ 1/10). Near-remission corresponds to remission for joint counts and C-reactive protein but with PGA > 1. The objective was to explore whether the contribution of PGA to remission and near-remission varied according to the wording of the PGA and in relation to disease duration. In patients with early arthritis (N = 731, French ESPOIR cohort) or established RA (N = 236 patients from across Europe), frequency of remission versus near-remission was assessed according to the phrasing used for PGA (global health versus disease activity). In 967 patients (mean [standard deviation] age 49.7 [12.7] years, 76.7% women), remission was infrequent: range 12.9–16.7% (according to wording of PGA) in early RA and 6.8–7.2% in established RA. Near-remission was more frequent: 13.0–16.8% in early RA and 13.1–13.6% in established RA. The ratio of remission to near-remission was higher in the early arthritis cohort (0.8–1.3 versus 0.5–0.5 in established RA). Using the disease activity PGA led to more remission and less near-remission than the global health PGA in the early arthritis cohort (12.9 vs 16.7% near-remission, respectively, p = 0.047) but not in established RA. The proportion of patients who can be classified as remission or near-remission differs in early RA compared to establish RA and depends upon the formulation of the PGA question. PGA referring to disease activity and not global health may be preferred in early disease, if the objective is more alignment with inflammation assessment.

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Acknowledgements

For the ESPOIR cohort, we wish to thank Nathalie Rincheval who performs expert monitoring and data management for ESPOIR, and all the investigators who recruited and followed the patients (F. BERENBAUM, Paris-Saint Antoine, MC. BOISSIER, Paris-Bobigny, A. CANTAGREL, Toulouse, B. COMBE, Montpellier, M. DOUGADOS, Paris-Cochin, P FARDELONNE and P BOUMIER, Amiens, B. FAUTREL, Paris-Pitié, RM. FLIPO, Lille, P. GOUPILLE, Tours, F. LIOTE, Paris-Lariboisière, O VITTECOQ, Rouen, X MARIETTE, Paris-Bicetre, O MEYER, Paris Bichat, A.SARAUX, Brest, T. SCHAEVERBEKE, Bordeaux and J. SIBILIA, Strasbourg).For RAID, we wish to thank Dr. Loreto Carmona (Spain) and the RAID patient research partners who participated in setting up the initial study.

RAID investigators co-authors as a group:

Dimitrios T. Boumpas, MD, FACP1; Ben A.C. Dijkmans, MD, MS3; Matthias Englbrecht, PhD4; Feride Gogus, MD5; Turid Heiberg, RN PhD6,7; Emilio Martin Mola, MD8; Marco Matucci Cerinic, MD9; Kati Otsa, MD10; Georg Schett, MD4; Marieke Scholte-Voshaar, MSc11; Tuulikki Sokka, MD, PhD12

1University of Crete, Faculty of Medicine, Heraklion, Greece

3VU University Medical Center and Jan van Breemen Institute, the Netherlands

4Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany

5University of Gazi, Ankara, Turkey

6Oslo University Hospital, Oslo, Norway

7Lovisenberg Diakonal College, Oslo, Norway

8Hospital Universitario La Paz, Madrid, Spain

9Division of Rheumatology AOUC, Denothe Centre, University of Florence, Firenze, Italy

10Tallinn Central Hospital, Estonia

11University of Twente, Netherlands

12Jyväskylä Central Hospital, Jyväskylä, Finland

Funding

The first author was partly funded by an Articulum Fellowship. The RAID study was funded by EULAR. The ESPOIR cohort was created and maintained through an unrestricted grant from Merck Sharp and Dohme (MSD) for the first 5 years; two additional grants from INSERM were obtained to support part of the biological database; the French Society of Rheumatology, Abbott, Pfizer and Roche-Chugai also supported the ESPOIR cohort study.

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Authors and Affiliations

  1. Sorbonne Université, Paris, France

    Laure Gossec, John Richard Kirwan, Maarten de Wit, Andra Balanescu, Cecile Gaujoux-Viala, Francis Guillemin, Anne-Christine Rat, Alain Saraux, Bruno Fautrel, Tore K Kvien & Maxime Dougados

  2. AP-HP, Pitié Salpêtrière Hospital, Department of rheumatology, Paris, France

    Laure Gossec, John Richard Kirwan, Maarten de Wit, Andra Balanescu, Cecile Gaujoux-Viala, Francis Guillemin, Anne-Christine Rat, Alain Saraux, Bruno Fautrel, Tore K Kvien & Maxime Dougados

  3. Academic Rheumatology Unit, Bristol Royal Infirmary, University of Bristol, Bristol, UK

    John Richard Kirwan

  4. EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland

    Maarten de Wit

  5. Department of Medical Humanities, VU University Medical Centre, Amsterdam, Netherlands

    Maarten de Wit

  6. Research Center of Rheumatic Diseases, “Sf. Maria” Hospital, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

    Andra Balanescu

  7. Department of Rheumatology, Nîmes University Hospital, Nîmes, France

    Cecile Gaujoux-Viala

  8. EA 2415, Montpellier University, Nîmes, France

    Cecile Gaujoux-Viala

  9. EA 4360 APEMAC, Nancy Hospital, Lorraine University, Nancy, France

    Anne-Christine Rat

  10. Department of Rheumatology, CHU de la Cavale Blanche, Brest, France

    Alain Saraux

  11. EA 2216, INSERM ESPRI, ERI29 Université Bretagne Occidentale, Brest, France

    Alain Saraux

  12. Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway

    Tore K Kvien

  13. Cochin Hospital, APHP, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris Descartes University, Paris, France

    Maxime Dougados

Authors
  1. Laure Gossec
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  2. John Richard Kirwan
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  3. Maarten de Wit
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  11. Maxime Dougados
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Consortia

the RAID investigators

  • Dimitrios T. Boumpas
  • , Ben A. C. Dijkmans
  • , Matthias Englbrecht
  • , Feride Gogus
  • , Turid Heiberg
  • , Emilio Martin Mola
  • , Marco Matucci Cerinic
  • , Kati Otsa
  • , Georg Schett
  •  & Tuulikki Sokka

Corresponding author

Correspondence to Laure Gossec.

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Key messages

1. Boolean remission is a state that is difficult to reach in RA, and PGA is the main limiting component: more than half of the patients with joint counts ≤ 1 and normal acute phase reactants are not attaining remission only because of PGA levels.

2. Among patients with normal/low joint counts and CRP, more patients did not reach remission because of PGA results in a cohort of established RA than in a cohort of early arthritis, indicating more discordance between PGA and objective criteria in established RA.

3. Remission was more frequent when using the disease activity PGA than the global health PGA in early arthritis, indicating disease activity PGA results are closer to examination and acute phase reactant results, than global health, at least in early disease.

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Gossec, L., Kirwan, J.R., de Wit, M. et al. Phrasing of the patient global assessment in the rheumatoid arthritis ACR/EULAR remission criteria: an analysis of 967 patients from two databases of early and established rheumatoid arthritis patients. Clin Rheumatol 37, 1503–1510 (2018). https://doi.org/10.1007/s10067-018-3998-1

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  • DOI: https://doi.org/10.1007/s10067-018-3998-1

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