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

Persistently different patterns of patient's global assessment of health in rheumatoid arthritis are associated with pain and impaired function more than with inflammation: an inception cohort study over 15 years

OBJECTIVE

To assess patient's self-reported global assessment of health (PGA) in relation to inflammation, pain and disability in patients with rheumatoid arthritis (RA).

METHODS

Data were obtained from the Better Anti-Rheumatic PharmacOTherapy early RA cohort, in which patients were scheduled for follow-up of 15 years. Longitudinal PGA trajectories were identified using hierarchical agglomerative clustering procedure with Wards methods, based on PGA assessments during the first 2 years. Multivariate linear regression and mixed models were used to evaluate associations between PGA, inflammation, pain and disability.

RESULTS

Totally 2238 patients were included in 1991-2006. Three PGA trajectories were identified, low, medium and high, including 34%, 48% and 18% of the patients, respectively. The similar PGA patterns were shown for the inclusion periods before and after 1999. The patients in the low PGA group were less often women, had lower body mass index, lower levels of inflammatory variables, visual analogue scale (VAS) pain and Health Assessment Questionnaire (HAQ) scores at baseline than patients in the higher PGA groups. After adjustments, smoking and antibodies to cyclic citrullinated peptide status differentiated between being in low and high PGA groups. During the first year, all PGA groups showed improved outcomes, most pronounced in low PGA group. Fewer patients in high PGA group achieved remission, independent of remission criteria used. The outcomes were consistently different between the PGA groups from 6 months and onwards. The PGA levels from baseline over 15 years were best explained by VAS pain, followed by HAQ score, Disease Activity Score on 28 joints-3 and tender joint count, adjusted R2 up to 77%, 41%, 27% and 26%, respectively.

CONCLUSION

Persistently higher PGA levels in RA were mostly related to pain and disability.

Disease activity and disease-related factors are drivers of patient global assessment in rheumatoid arthritis: a real-life cross-sectional study

Despite that the Patient Global Assessment (PGA) is widely used for measuring Rheumatoid Arthritis (RA) disease activity to define the remission state of the disease, the primary contributors influencing patients' ratings are still debated. This study aims to determine which clinical, sociodemographic and lifestyle-related contextual factors might be key drivers of PGA in RA. This single-center cross-sectional study recruited 393 consecutive adult RA patients. Median age 60 years, females 306 (77.9%). Data related to disease activity were assessed by using Simplified Disease Activity Index (SDAI), severity by Health Assessment Questionnaire (HAQ), and impact by RA Impact of Disease (RAID). Sociodemographic/lifestyle features were collected. Disease remission was calculated using Boolean-based criteria 1.0 and 2.0. Quantile regression models were used for univariate and multivariate analysis. The remission rate progressively increased from 15% by using SDAI with a Boolean 1.0-based definition to 43.5% using a Boolean 2.0-based remission. Among factors related to disease activity, the use of low-dose corticosteroids, the RAID items pain and sleep difficulties were predictive for worse PGA scores (p = 0.01). Among factors related to disease severity HAQ score and RAID total were independent factors associated with higher median PGA (p = 0.02 and p < 0.001). RAID's physical well-being was related to PGA scores (p = 0.01). An increasing trend in PGA was observed in longstanding diseases (> 15 years). Our results confirmed that there is no unambiguous interpretation of the PGA score. It is a measure related to some disease activity parameters, but it is also influenced by contextual factors related to disease severity and impact. These data highlighted that PGA should have a broad interpretation, thus supporting the proposal of a dual targets (biological and impact) approach to obtain a more accurate estimate of disease activity.

Patient Experienced Symptom State in rheumatoid arthritis: sensitivity to change in disease activity and impact

OBJECTIVES

The Patient Experienced Symptom State (PESS) is a single-question, patient-reported outcome that is validated to assess global disease impact in RA. This study addresses its sensitivity to change, and reliability.

METHODS

Disease activity, disease impact in the seven domains of RA Impact of Disease (RAID) and PESS were assessed in patients with RA from the NOR-DMARD registry, at two visits, 6 months apart. The PESS over the last week was scored at five levels, from 'very bad' to 'very good'. Disease impact and disease activity were compared between patients who improved, maintained or worsened PESS over time, through one-way analysis of variance, with post hoc Bonferroni correction. Correlations between changes in these parameters were assessed through Spearman's correlation coefficient. Sensitivity to change was assessed by standardized response mean (SRM) between the two visits. Reliability was analysed through intraclass correlation coefficient (ICC) between the two visits in patients with stable disease activity and impact.

RESULTS

In 353 patients [76.8% females, mean (s.d.) 9.9 (9.6) years disease duration], improvement in PESS level was associated with substantial improvements in mean impact in all domains as well as disease activity (P <0.02). PESS change was moderately to strongly correlated with RAID domains and disease activity (rho: 0.4-0.7). PESS was responsive to change (SRM: 0.65, 95% CI: 0.54, 0.76), particularly among RAID responders (SRM: 1.79, 95% CI: 1.54, 1.99). PESS was moderately reliable in patients with stable condition (ICC: 0.72, 95% CI: 0.52, 0.83).

CONCLUSION

PESS is valid, feasible, reliable and responsive, representing an opportunity to improve the assessment of disease impact with minimal questionnaire burden.

Remission or Not Remission, That's the Question: Shedding Light on Remission and the Impact of Objective and Subjective Measures Reflecting Disease Activity in Rheumatoid Arthritis

Introduction

The inclusion of certain variables in remission formulas for rheumatoid arthritis (RA) may give rise to discrepancies. An increase in patient global assessment (PGA), a variable showing the patient's self-evaluation of their disease activity, may alone tilt a patient out of remission when using certain remission-assessing methods. This study aimed to explore differences in remission rates among various formulas and the impact of PGA and other clinical variables on the calculation of remission.

Methods

Data were collected from RA patients monitored during the years 2015–2019 at an outpatient clinic in southern Norway. Linear and logistic regression assessed associations between PGA, other RA-related variables, and remission-assessing methods.

Results

Remission rates were 23%, 65%, and 73% in 2019 when assessing the same 502 RA patients using Boolean remission, Boolean remission without PGA, and the disease activity score (DAS) with C-reactive peptide [DAS28(3)-CRP] method, respectively. Among the same population that year, 27% reported PGA ≤ 10, 74% had a tender joint count of ≤ 1, 85% had a swollen joint count of ≤ 1, and 86% had CRP ≤ 10. Pain (standardized coefficient β = 0.7, p < 0.001) was most strongly associated with PGA. Pain, fatigue, and morning stiffness were substantially associated with the remission-assessing methods that incorporated PGA.

Conclusions

Since PGA is strongly associated with the patient’s perception of pain and may not reflect the inflammatory process, our study challenges the application of remission-assessing methods containing PGA when monitoring RA patients in the outpatient clinic. We recommend using measures that are less likely to be associated with noninflammatory pain and psychosocial factors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00490-5.

Influence of frailty on patient global assessment in rheumatoid arthritis

AIM

Patient Global Assessment (PtGA; range 0-10 cm) is an important indicator of clinical outcomes, including physical function, in self-assessment of patients with rheumatoid arthritis (RA). Frailty is a concept that encompasses not only physical, but also mental, psychological and social vulnerability. This study aimed to investigate the influence of frailty on PtGA in patients with RA.

METHODS

Among 581 patients with RA who completed a questionnaire survey on frailty between June and August 2020, 559 who completed the Kihon Checklist (KCL; a 25-item questionnaire with seven domains) were included. The proportion of patients with PtGA ≤1 was compared between the frailty (KCL score ≥8), pre-frailty (KCL score 4-7) and robust (KCL score 0-3) groups. Factors associated with PtGA ≤1 were examined using multivariate logistic regression models.

RESULTS

Of the 559 patients, 221 (39.5%) had frailty. The proportion of patients with PtGA ≤1 was significantly lower in the frailty group (33.9%) than in the robust (65.4%, P < 0.001) and pre-frailty (55.7%, P < 0.001) groups. Multivariate analysis revealed that frailty (vs robust, OR 0.37, 95% CI 0.22-0.69), as well as disease duration and tender joint count, were factors independently associated with PtGA ≤1. When each domain of the KCL was examined, activities of daily living, physical strength, isolation and depressive mood were factors associated with PtGA ≤1.

CONCLUSION

Frailty affects PtGA in patients with RA. As frailty impacts the physical, mental and social vulnerability aspects of PtGA, a multifaceted approach, including inflammation suppression, is required to improve PtGA in patients with RA. Geriatr Gerontol Int 2022; 22: 399-404.

Effectiveness of Etanercept in Rheumatoid Arthritis: Real-World Data from the German Non-interventional Study ADEQUATE with Focus on Treat-to-Target and Patient-Reported Outcomes

BACKGROUND

For rheumatoid arthritis (RA), the treat-to-target concept suggests attaining remission or at least low disease activity (LDA) after 12 weeks.

OBJECTIVES

This German, prospective, multicenter, non-interventional study aimed to determine the proportion of patients with RA who achieved their treat-to-target aim after 12 and 24 weeks of etanercept (ETN) treatment in a real-life setting, as opposed to patients achieving their therapeutic target at a later timepoint (week 36 or 52).

METHODS

A total of 824 adults with a confirmed diagnosis of RA without prior ETN treatment were included. Remission and LDA were defined as DAS28 < 2.6 and DAS28 ≤ 3.2, respectively.

RESULTS

The proportion of patients achieving remission was 24% at week 12 and 31% at week 24. The proportion of patients achieving LDA was 39% at week 12 and 45% at week 24. The proportion of patients achieving remission or LDA further increased beyond week 24 up to week 52. Improvement in pain and reduction in concomitant glucocorticoid treatment were observed. Improvements in patient-reported outcomes were also seen in patients who did not reach remission or LDA. No new safety signals were detected.

CONCLUSIONS

A considerable proportion of patients with RA attained the target of remission or LDA after 12 weeks of ETN treatment. Even beyond that timepoint, the proportion of patients achieving treatment targets continued to increase up to week 52.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02486302.

Treating-to-target in rheumatology: Theory and practice

Despite its inclusion in current treatment recommendations, adherence to the treat-to-target strategy (T2T) is still poor. Among the issues are the definition(s) of target, especially the caveats of the patient global assessment (PGA), included in all recommended definitions of remission. The PGA is poorly related to inflammation, especially at low levels of disease activity, rather being a measure of the disease impact. Up to 60% of all patients otherwise in remission still score PGA at >1 and as high as 10. These patients (PGA-near-remission) are exposed to overtreatment if current recommendations are strictly followed and will continue to endure significant impact, unless adjuvant measures are implemented. A proposed method to overcome both these risks is to systematically pursue two targets: one focused on the disease process (the biological target) and another focused on the symptoms and impact (the impact target), the dual-target strategy. Candidate instruments to define each of these targets are discussed.

Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis

Background:

The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status.

Methods:

Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables.

Results:

After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months].

Conclusion:

In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.

Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients

OBJECTIVES

To determine the impact of excluding patient global assessment (PGA) from the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission criteria, on prediction of radiographic and functional outcome of rheumatoid arthritis (RA).

METHODS

Meta-analyses using individual patient data from randomised controlled trials testing the efficacy of biological agents on radiographic and functional outcomes at ≥2 years. Remission states were defined by 4 variants of the ACR/EULAR Boolean definition: (i) tender and swollen 28-joint counts (TJC28/SJC28), C reactive protein (CRP, mg/dL) and PGA (0-10=worst) all ≤1 (4V-remission); (ii) the same, except PGA >1 (4V-near-remission); (iii) 3V-remission (i and ii combined; similar to 4V, but without PGA); (iv) non-remission (TJC28 >1 and/or SJC28 >1 and/or CRP >1). The most stringent class achieved at 6 or 12 months was considered. Good radiographic (GRO) and functional outcome (GFO) were defined as no worsening (ie, change in modified total Sharp score (ΔmTSS) ≤0.5 units and ≤0.0 Health Assessment Questionnaire-Disability Index points, respectively, during the second year). The pooled probabilities of GRO and GFO for the different definitions of remission were estimated and compared.

RESULTS

Individual patient data (n=5792) from 11 trials were analysed. 4V-remission was achieved by 23% of patients and 4V-near-remission by 19%. The probability of GRO in the 4V-near-remission group was numerically, but non-significantly, lower than that in the 4V-remission (78 vs 81%) and significantly higher than that for non-remission (72%; difference=6%, 95% CI 2% to 10%). Applying 3V-remission could have prevented therapy escalation in 19% of all participants, at the cost of an additional 6.1%, 4.0% and 0.7% of patients having ΔmTSS >0.0, >0.5 and >5 units over 2 years, respectively. The probability of GFO (assessed in 8 trials) in 4V-near-remission (67%, 95% CI 63% to 71%) was significantly lower than in 4V-remission (78%, 74% to 81%) and similar to non-remission (69%, 66% to 72%).

CONCLUSION

4V-near-remission and 3V-remission have similar validity as the original 4V-remission definition in predicting GRO, despite expected worse prediction of GFO, while potentially reducing the risk of overtreatment. This supports further exploration of 3V-remission as the target for immunosuppressive therapy complemented by patient-oriented targets.

Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database

OBJECTIVE

There is an ongoing debate about excluding patient's global assessment (PtGA) from composite and Boolean-based definitions of rheumatoid arthritis (RA) remission. This study aimed at determining the influence of PtGA on RA disease states, exploring differences across countries, and understanding the association between PtGA, measures of disease impact (symptoms), and markers of disease activity (inflammation).

METHODS

Cross-sectional data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology international database were used. We calculated the proportion of patients failing American College of Rheumatology/European League Against Rheumatism Boolean-based remission (4-variable remission) solely due to PtGA (PtGA-near-remission) in the overall sample and in the most representative countries (i.e., those with >3,000 patients in the database). Multivariable linear regression models were used to identify the main determinants of PtGA, grouped in predominantly inflammatory impact factors (28 tender joint counts, 28 swollen joint counts, and C-reactive protein level) and disease impact factors (pain and function).

RESULTS

This study included 27,768 patients. Excluding PtGA from the Boolean-based definition (3-variable remission) increased the remission rate from 5.8% to 15.8%. The rate of PtGA-near-remission varied considerably between countries, from 1.7% in India to 17.9% in Portugal. One-third of the patients in PtGA-near-remission group scored PtGA >4 of 10. Pain and function were the main correlates of PtGA, with inflammation-related variables contributing less to the model (R² = 0.57).

CONCLUSION

PtGA is moderately related to joint inflammation overall, but only weakly so in low levels of disease activity. A considerable proportion of patients otherwise in biologic remission still perceive high PtGA, putting them at risk of excessive immunosuppressive treatment.

The epidemiology of established rheumatoid arthritis

No published epidemiological study has specifically focused on the prevalence of established rheumatoid arthritis (RA), as epidemiologists do not study established RA separated from RA as a whole; especially no incidence studies can be found, as incidence refers to new cases (early RA). Such a study, if it existed, would find a prevalence much larger than that of recent-onset RA, and should be planned based on clear definitions that currently do not exist in epidemiology. As a result, any study addressing RA as a whole, leaving aside early arthritis, would be actually studying established RA. This work reviews the epidemiology of RA, in contraposition of early RA, and tried to highlight epidemiological characteristics of established RA in published studies as well as methodological issues, including differences between recent-onset and established RA regarding the prevalence of comorbidities and other characteristics, and differences across countries. The global epidemiology of established RA teaches us that long-term outcomes could largely depend on health care models and are modifiable.