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The distance from 1 to 2 is not easy ~
Since rheumatoid arthritis (RA) is still not curable, preventing joint destruction deformity is very important
for the prognosis of patients.
Joint destruction deformity
can only be prevented with aggressive treatment that brings the patient's disease to clinical remission or low disease activity and is maintained throughout the course of the disease.
What do you think of the 3 commonly used clinical remission indicators?
There are many standards for clinical remission, and the Boolean remission criteria and exponential remission criteria [Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)] are widely used
because of their simple calculation and strong practicality.
The Boolean relief criteria are also known as the "four 1s" criteria, that is, the joint swelling count (SJC) and joint tenderness count (TJC) should be less than 1, the value of C-reactive protein (CRP) should be less than 1mg/dl, and the overall patient assessment (PGA) should be less than 1 (0-10cm).
From the patient's point of view, it can be simply understood that there is basically no joint swelling and pain, and inflammatory indicators such as erythrocyte sedimentation rate and CRP are reduced to normal
.
The SDAI remission criterion refers to any point in time in which the patient's SDAI index is less than 3.
3
.
SDAI assessment is generally based on 28 joints: bilateral proximal interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, and knee.
SDAI Total Score = SJC+TJC+PGA+MDGA+CRP
Note: MDGA: Physician's Overall Assessment (0-10 points)
The SDAI mitigation criteria are not as stringent as the Boolean mitigation criteria, which allow PGA>1
.
In addition to the Boolean mitigation standard and the SDAI mitigation standard, CDAI is also a very authoritative standard, and the CDAI mitigation standard is a total score of ≤ 2.
8
.
CDAI assessments are generally based on 28 joints: bilateral proximal interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, and knee.
CDAI total score = SJC+TJC+PGA+MDGA
There are still limitations to the current standard
Although the same ACR/EULAR standard, some patients who achieve SDAI remission do not meet the stricter definition of Boolean remission, mainly because the Boolean remission standard requires PGA≤1, so PGA has been criticized for not fully reflecting the disease activity of RA
.
Previous studies have shown that a higher PGA threshold may improve consistency
between the Boolean mitigation criteria and the SDAI mitigation criteria.
New standards have appeared!
The following quantitatively validated study using independent patient data also suggests that increasing the PGA standard threshold from 1 to 2 results in more patients being defined as Boolean remission and increasing its agreement with SDAI response criteria without compromising its predictive value
for imaging or functional outcomes.
Therefore, ACR/EULAR revised the mitigation standard for RA, and the current Boolean mitigation standard has been revised to Boolean 2.
0, that is, SJC and TJC are less than 1, the value of CRP is less than 1mg/dl, and the PGA is less than 2 (0-10cm).
Figure 1: Screenshot of the literature study The study used data from 4 randomized trials with a total of 2048 participants, including 1101 patients with early-stage RA (mean duration of
disease 0.
8±0.
5 years) and 947 patients with confirmed RA (mean duration 7.
1±5.
4 years).
。 To analyze the agreement between different Boolean remission criteria and exponential remission criteria (SDAI and CDAI), and to explore the effectiveness of
different remission criteria in predicting future good physical function [Health Assessment Questionnaire (HAQ) score ≤0.
5] and radiographic progression.
The researchers increased the PGA standard threshold from 1 to 2.
5, labeling it as Boolean 1.
0, Boolean 1.
5, Boolean 2.
0 and Boolean 2.
5
, respectively.
Boolean excluding PGA is labeled Boolean X, i.
e.
Boolean X mitigation
can be obtained as long as CRP, TJC, and SJC are all ≤1, regardless of the PGA value.
Studies have shown that the agreement between Boolean 2.
0 and SDAI or CDAI remission criteria is better than Boolean 1.
0, especially in the early stages of the disease (Figure 2).
Figure 2: Response rates for RA disease based on different response criteria
TheKAppa analysis also showed that the agreement between the SDAI mitigation standard and the Boolean2.
0 mitigation standard was significantly higher than that of the Boolean 1 0 mitigation criteria (Figure 3).
However, when the PGA threshold is further increased to greater than 2, the consistency of SDAI mitigation and Boolean mitigation gradually decreases
.
Figure 3: Consistency
between modified Boolean mitigation criteria and SDAI mitigation criteria.
Note: Patients with early RA (red line), patients with confirmed RA (green line), all patients with RA (blue line).
The accuracy of
different response criteria for predicting good physical function outcomes (HAQ≤0.
5) and no radiographic progress (ΔmTSS) at year 1 was also explored.
Table 1 summarizes the similarity of different response criteria at six months in predicting radiographic progression at year 1
.
Studies have shown that radiological outcomes are similar regardless of PGA threshold and whether or not PGA is included in the Boolean criteria, and scores are similar
between different measures of response.
Boolean 2.
0, SDAI, and CDAI remission criteria have similar positive likelihood ratios (LRs) to predict radiographic progression and future good bodily functioning outcomes
.
However, without the use of PGA (BooleanX), its accuracy in predicting good bodily function is reduced
.
Table 1: Rates and LR* of patients with RA who have recovered well to function after 1 year (HAQ≤0.
5) and/or radiologically progression-free (ΔmTSS*, depending on the criteria for response
total
knot
Overall, there was better consistency between the use of Boolean 2.
0 as the PGA (Boolean 2.
0) threshold and the SDAI remission criteria, which classified more patients as clinical remission
.
At the same time, the use of Boolean 2.
0 did not affect its value
in predicting radiographic progression or functional outcomes.
In addition, patients who met the criteria for remission of Boolean 2.
0, CDAI, and SDAI at 6 months were more likely to achieve good functional and radiographic outcomes after 12 months of treatment than those who
had the Boolean X remission criteria.
References:
[1] Aletaha D,Neogi T,Silman AJ,et al.
2010 rheumatoid arthritis classification criteria:an American College of Rheumatology/European League Against Rheumatism collaborative initiative[ published correction appears in Ann Rheum Dis.
2010 Oct; 69(10):1892].
Ann Rheum Dis.
2010; 69(9):1580-1588.
doi:10.
1136/ard.
2010.
138461
[2] Studenic P,Aletaha D,de Wit M,et al.
American College of Rheumatology/EULAR Remission Criteria for Rheumatoid Arthritis:2022 Revision[published online ahead of print,2022 Oct 23].
Arthritis Rheumatol.
2022; 10.
1002/art.
42347.
doi:10.
1002/art.
42347
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