Elsevier

Joint Bone Spine

Volume 81, Issue 5, October 2014, Pages 409-415
Joint Bone Spine

Original article
Prevalence and concordance of early and sustained remission assessed by various validated indices in the early arthritis “ESPOIR” cohort

https://doi.org/10.1016/j.jbspin.2014.02.007Get rights and content

Abstract

Objectives

To assess the prevalence of remission in early arthritis, to evaluate the concordance across different criteria sets in defining this state, and to look for predictive factors for early and sustained remission.

Methods

Patients from the ESPOIR cohort were followed-up every 6 months. We analysed early remission and sustained remission in 3 groups of patients: patients having rheumatoid arthritis (RA) according to 2010 ACR/EULAR criteria, undifferentiated arthritis (UA), and the whole cohort. Remission was defined according to ACR/EULAR criteria, 28 Joint Disease Activity Score (DAS28 < 2.6), and Simplified Disease Activity Index (SDAI  3.3). Agreement was evaluated by k-coefficient. Predictive factors for sustained remission at 1, 3 and 5 year in RA patients were analyzed.

Results

Eight hundred and nineteen patients were included. Early remission rates in the RA/UA/ESPOIR groups were observed in respectively 29.2% (181/682), 51.4% (55/123) and 32.7% (239/813) of patients by DAS28; 15.7%, 29.1% and 18% by SDAI; and 11.2%, 29.1% and 12.8% by ACR/EULAR criteria. Agreement between classifications of remission was low for DAS28 vs. ACR/EULAR (k = 0.44), high for SDAI vs. ACR/EULAR (k = 0.78), and moderate for SDAI vs. DAS28 (k = 0.54). Lower baseline disease activity scores, non-menopausal status and younger age were the best predictive factors for sustained remission, with consistent results across the 3 definitions of remission.

Conclusion

Our study showed that the rate of early and sustained remission in early arthritis is dependent on the definition used, with a variable degree of agreement across criteria sets, but with consistent predictive factors of favourable outcome in patients finally diagnosed with RA.

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease that is characterized by joint inflammation leading to joint destruction. This causes decreased functional capacity, work disability, and reduced quality of life [1]. Studies evaluating tight control and treat-to-target strategies advocate that remission should be reached as soon as possible and should ideally be maintained during the course of the disease [2], [3]. Since a cure has not yet been established for rheumatoid arthritis (RA), the best achievable state in patients with RA is remission. However, the best way to define remission is still under debate. Categories of high, moderate, and low disease activity as well as remission have been identified for the most commonly used indices: the disease activity score using 28 joint counts (DAS28) [4], and Simplified Disease Activity Index (SDAI) [5]. The American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) recently proposed new definitions of remission in RA for clinical trials, which could also be used as the primary outcome of clinical trials and real life practice [6], [7]. Testing these new remission criteria in RA cohorts was encouraged to determine their practicality for daily use [6]. Recently, a validation of these criteria using the ESPOIR study showed that patients in ACR/EULAR remission in ESPOIR had a high rate of later radiographic and functional stability, and suggests that these definitions of remission are valid in clinical practice settings [8].

Better knowledge about prevalence and prognostic factors for remission might improve patient care according to their individual profile. Only a few studies have examined sustained remission in usual clinical settings [9], [10], [11]. In the literature, definitions of sustained remission in RA vary considerably in both measurement and duration, and whether discontinuation of antirheumatic treatment is a prerequisite remains also debated.

The aim of this study was to assess the prevalence of remission during the initial follow-up of a cohort of patients with early inflammatory arthritis, to evaluate the concordance across different criteria sets in defining this state, and to look for predictive factors for early and sustained remission in RA patients.

Section snippets

Source data

The ESPOIR cohort is a nationwide prospective cohort study of adults in France conducted under the auspices of the French Society of Rheumatology [12]. The study was approved by the Institutional Review Board of the Montpellier University Hospital, which was the coordinating center. Prior to inclusion, written informed consent was obtained from each participant.

This cohort has included 813 patients with early arthritis between December 2002 and March 2005. Forteen participating investigational

Demographic, clinical and biological characteristics of the 3 groups of patients

Table 1 shows the baseline characteristics of the patients. The mean age was 48.5 ± 12.2 years, 46.5 ± 13.7, and 48.1 ± 12.6 for patients who were diagnosed as having RA after 1 year of follow-up, UA and the whole cohort, respectively. Among the RA patients, 371 (55,5%) had high disease activity at baseline (DAS28 > 5.1) vs. 392 (49.5%) of the whole cohort and 20 (16.4%) of the UA.

Remission rate at 6 months follow-up visit according to the 3 definitions in the 3 groups of the patients

Early remissions in the RA patients, UA and the whole cohort were observed in respectively 29.2%, 51.4% and 32.7% of patients

Discussion

Early remission rates in the RA/UA/ESPOIR groups were observed in one third approximately of RA patients by DAS28; and in one fifth of patients by SDAI and ACR/EULAR criteria. Occurrence of remission at all time points was lowest for the ACR/EULAR clinical trial criteria, making it the most stringent remission definition. Baseline low disease activity, pre-menopausal status and younger age predicted the clinical remission.

Our results echo the work of others, demonstrating higher response rates

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgements

The authors wish to thank all investigators who recruited and followed the patients (F. Berenbaum, Paris-Saint-Antoine; M.C. Boissier, Paris-Bobigny; A. Cantagrel, Toulouse; H. Cholvy, Montpellier; M. Dougados, Paris-Cochin; P. Fardelone and P. Boumier, Amiens; B. Fautrel, Paris-La Pitié; R.M. Flipo, Lille; P. Goupille, Tours; F. Liote, Paris-Lariboisière; X. Le Loet and O. Vittecoq, Rouen; X. Mariette, Paris-Bicêtre; O. Meyer, Paris-Bichat; A. Saraux, Brest; T. Schaeverbeke, Bordeaux;

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