Ferreira R, Duarte C, Ndosi M, de Wit M, Gossec L, da Silva J

OBJECTIVES In current management paradigms of Rheumatoid Arthritis (RA), patient global assessment (PGA) is crucial to decide whether a patient has attained remission (target) or needs reinforced therapy. We investigated whether the clinical and psychological determinants of PGA are appropriate to support this important role.

METHODS This was a cross-sectional, single centre study including consecutive ambulatory RA patients. Data collection comprised swollen (SJC28) and tender joint counts (TJC28), C-Reactive protein (CRP), PGA, pain, fatigue, function, anxiety, depression, happiness, personality traits, and comorbidities. Remission was categorised using ACR/EULAR Boolean-based criteria: remission, near-remission (only PGA>1) and non-remission. A binary definition without PGA (3v-Remission) was also studied. Univariable and multivariable analyses were used to identify explanatory variables of PGA in each remission state.

RESULTS 309 patients were included (remission: 9.4%; near-remission: 37.2%; non-remission: 53.4%). Patients in near-remission were indistinguishable from remission regarding disease activity, but described a disease impact similar to those in non-remission. In multivariable analyses, PGA in near-remission was explained (R(2)adjusted =.50) by fatigue, pain, anxiety and function. Fatigue and pain had no relationship with disease activity measures.

CONCLUSION In RA, a consensually acceptable level of disease activity (SJC28, TJC28, and CRP≤1) does not equate to low disease impact: a large proportion of these patients are considered in non-remission solely due to PGA. PGA mainly reflects fatigue, pain, function, and psychological domains, which are inadequate to define the target for immunosuppressive therapy. This suggests that clinical practice should be guided by two separate remission targets: inflammation (3v-Remission) and disease impact.

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