What are the characteristics of RA patients who can achieve "deep clinical remission"?

*Only for medical professionals to read for reference.
Deep relief, get it~ Due to the high disability of rheumatoid arthritis (RA), it seriously affects the patient's functional status and quality of life, and causes a huge social and economic burden
.

In recent years, clinical remission has become a feasible clinical goal, so more and more clinical studies are exploring more stringent goals, such as early remission, clinical deep remission, continuous clinical remission, etc.
, to optimize RA management strategies and improve patient outcomes
.

At the 23rd Asia-Pacific Rheumatism Alliance (APLAR) conference that was just concluded, Professor Li Ru from Peking University People's Hospital gave wonderful insights on the clinical deep relief of RA! Clinical remission still has residual disease activity, and higher requirements have emerged.
Professor Li Ru mentioned that clinical remission is currently widely accepted as the target of RA treatment
.

However, the remission standards for different indicators are different.
How to judge "clinical remission" is currently commonly used in the following definitions: disease activity (DAS28)-ESR or CRP ≤ 2.
6; clinical disease activity index (CDAI) ≤ 2.
8; simplified disease activity index (SDAI) ≤3.
3; meet the Boolean mitigation standard
.

When the above standards cannot be met, low disease activity can be used as the treatment goal, that is, DAS28≤3.
2 or CDAI≤10 or SDAI≤11
.

Follow up with close monitoring of the condition.
Patients whose condition has not improved within 3 months or cannot reach the target within 6 months should be adjusted to a more aggressive treatment plan
.

Figure 1: Clinical remission is the main goal of RA treatment.
However, in recent years, studies have found that even if RA patients achieve clinical remission, they still have varying degrees of residual disease activity.
More and more scholars have proposed "CliDR" This concept
.

Where is this depth reflected? "Clinical deep relief" means that the patient has reached a state where there is no joint swelling and tenderness (the number of swollen joints: SJC=0, the number of tender joints: TJC=0), and the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are normal
.

Multiple factors affect the remission rate of CliDR.
Then, Professor Li Ru introduced to us a recent online publication in The Lancet Regional Health (WP), a sub-journal of Lancet, entitled "Multi-center real world of clinical remission of rheumatoid arthritis in the Asia-Pacific region.
Research results (Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region)"
.

This is a real-world cross-sectional survey of RA remission rates in APLAR countries and regions led by Peking University People’s Hospital, and analysis of relevant factors of clinical remission [1]
.

This multi-center, large-sample RA remission rate study in the Asia-Pacific region included 2010 RA patients in 17 centers in 11 countries and passed different remission standards (including DAS28-CRP, DAS28-ESR, CDAI, SDAI, Boolean, and CliDR).
Six standards), analyze the RA remission rate and its influencing factors
.

In the figure below, you can see that the applied clinical remission standards are different, and the remission rate is also different.
DAS28-CRP has the highest remission rate (62.
31%), and the remission rate of CliDR is the lowest (17.
06%); while the remission rate of CliDR is in different countries It is also different.
Kuwait has the highest CliDR remission rate, followed by Japan.
The CliDR remission rate of these two countries is significantly higher than that of other countries, and the difference is statistically significant
.

Figure 2: Remission rate of RA patients in the Asia-Pacific region Figure 3: Comparison of CliDR remission rate in different countries and regions The table below shows that among patients who meet the CilDR remission criteria, there are fewer women, younger ages and fewer comorbidities , And the number of higher education and BMI index are higher than those of non-CliDR remission standards
.

Table 1: The difference between patients meeting CliDR remission criteria and non-CliDR remission criteria.
After multi-factor Logistic regression correction for age and gender, it was found that the use of biological anti-rheumatic drugs or targeted synthetic DMARDs (b/tsDMARDs) and RA Clinical remission was positively correlated
.

The study proved that factors that are conducive to alleviation include males, young patients, and fewer complications
.

It was further found that with different b/tsDMARDs, there was no statistically significant difference in the remission rate of CliDR
.

In other words, the type of biological agent has no effect on the CliDR remission rate! Figure 4: Comparison of the remission rates of different b/tsDMARDs.
The clinical utility of CliDR is better.
In order to further study the practicability of these standards, 43 rheumatologists evaluated various remission standards on a scale of 0-10.
10 means the strongest practicality, 0 means the worst practicality
.

The study found that CliDR scored the highest compared to other standards! Real-world studies have confirmed that continuous intensive treatment has a higher remission rate! How about the performance of CliDR mitigation standards in real-world research? A 5-year real-world longitudinal cohort study of Peking University People's Hospital [2] analyzed the effect of continuous active treatment on the long-term remission of RA
.

The study included 541 RA patients with a total of 2588 follow-up visits.
During the 5-year follow-up, 207 patients received continuous intensive treatment with DMARDs (SUIT, using ≥2 DMARDs for more than 6 months), and 152 patients received non-SUIT treatment And 182 patients were treated with intermittent SUIT
.

The study found that the baseline drug usage rate was Leflunomide (LEF) 56.
7%> Methotrexate (MTX) 40.
1%> Hydroxychloroquine (HCQ) 32.
3%> Oral hormone 29.
8%> Sulfasalazine (SSZ) 17.
7%＞bDMARD 7.
0%＞Iramod (IGU) 0.
7%
.

Figure 5: Drug use rate at baseline The following figure shows: 1.
The sustained remission rate of CliDR decreased with time; 2.
The sustained remission rate and cumulative remission rate of CliDR in the SUIT group were significantly higher than those in the non-SUI group and intermittent SUIT Group
.

Figure 6: Changes in continuous and cumulative CliDR remission rate over time.
Therefore, clinically, patients with RA should not be reduced or discontinued after their symptoms have improved, but should continue to be treated for a longer period of time to facilitate continuous remission of the disease and improve the prognosis
.

Regression analysis explored the predictors of sustained CliDR remission.
Univariate analysis found that age, ESR, SJC28, and SUIT treatment were related to sustained CliDR remission, while multivariate analysis found that age and SUIT treatment were independent predictors of sustained CliDR remission
.

Table 2: Predictors of sustained CliDR remission.
We further compared whether there is a difference in drug choice between CliDR remission patients and non-CliDR remission patients.
It was found that fewer patients in CliDR remission chose hormone and methotrexate therapy
.

Summary: At the end of the conference, Professor Li Ru summarized the topic: 1.
CliDR may be a feasible standard for clinical deep relief; 2.
Male, less comorbidities, and the use of biological agents are independent factors for CliDR relief; 3.
In real-world studies, continuous intensive treatment with DMARDs can lead to a higher rate of sustained CliDR remission
.

References: [1]Sun X,Li R,Cai YM,et al.
Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region[J].
The Lancet Regional Health-Western Pacific 15(2021) 100240.
[2]Cai YM,Li R,Ye H,et al.
Effect of sustained intensive therapy with disease modifying anti-rheumatic drugs in rheumatoid arthritis:a 5-year real-world consecutive study.
Chin Med J(Engl)2020 ;133:1397-1403.