Suppressing Inflammation in Rheumatoid Arthritis: Does Patient Global Assessment Blur the Target? A Practice‐Based Call for a Paradigm Change

Abstract

Objective 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‐center study including consecutive ambulatory RA patients. Data collection comprised swollen 28‐joint count (SJC28), tender 28‐joint count (TJC28), C‐reactive protein (CRP) level, PGA, pain, fatigue, function, anxiety, depression, happiness, personality traits, and comorbidities. Remission was categorized using American College of Rheumatology/European League Against Rheumatism Boolean‐based criteria: remission, near‐remission (only PGA >1), and nonremission. 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 A total of 309 patients were included (remission 9.4%, near‐remission 37.2%, and nonremission 53.4%). Patients in near‐remission were indistinguishable from remission regarding disease activity, but described a disease impact similar to those in nonremission. In multivariable analyses, PGA in near‐remission was explained (R2adjusted = 0.50) 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 level ≤1) does not equate to low disease impact: a large proportion of these patients are considered in nonremission solely due to PGA. PGA mainly reflects fatigue, pain, function, and psychological domains, which are inadequate to define the target for immunosuppressive therapy. This consideration suggests that clinical practice should be guided by 2 separate remission targets: inflammation (3v‐remission) and disease impact.

Limited Health Literacy and Patient Confusion About Rheumatoid Arthritis Patient Global Assessments and Model Disease States

“…Debate is ongoing about the future of the PGA‐VAS in RA remission criteria. Proposals include removing the PGA‐VAS from remission criteria , using model disease states to orient the patients to a standard of comparison similar to that used by providers , using patient‐reported outcomes that capture the patient perspective of remission to either replace or augment the PGA‐VAS , or to raise the PGA‐VAS remission target to a more forgiving level . In light of these controversies, our data, which question the validity of model disease state ratings and difficulties in VAS completion for those of limited health literacy and with possible mental health issues, are particularly valuable and add urgency to the growing sense that the PGA‐VAS needs to be re‐examined as a criterion of remission .…”

Shared decision‐making in people with chronic disease: Integrating the biological, social and lived experiences is a key responsibility of nurses

“…First, we demonstrated that there were almost twice as many patients in PGA‐near‐remission status as those in “full” remission in an international cohort (Ferreira, Carvalho, et al, ), and up to 37% of all patients in some settings (Ferreira, Duarte, et al, ). Among these PGA‐near‐remission patients, about one‐third scored a PGA >4/10 (Ferreira, Carvalho, et al, ).…”

“…Finally, we showed that PGA from patients in near‐remission is not associated with disease activity but rather with fatigue, pain, anxiety, depression, physical well‐being and functional limitations (Ferreira et al, ; Ferreira, Duarte, et al, , Ferreira, Carvalho, et al, ).…”

The controversy of using PGA to define remission in RA

“…Rheumatol. 13, 573-574 (2017)) 1 referring to our paper on the role of patient global assessment (PGA) in the definition of remission in rheumatoid arthritis (RA) 2 . However, we cannot agree with their interpretation that by suggesting to remove the PGA from the ACR/EULAR remission definition we are "calling for a paradigm change that limits the responsibility of the rheumatologist to prescribing immunosuppressive therapy, " or that our proposal is "taking away the incentive to improve RA care by removing the patient's perspective from the remission criteria. "…”

“…This consideration suggests that clinical practice should be guided by two separate remission targets: inflammation (3v-remission) and disease impact. " 2 In summary, we do not propose to "limit the responsibility of the rheumatologist to prescribing immunosuppressive therapy" 1 , but rather we want to highlight the rheumatologist´s and multidisciplinary team's responsibility to assess and manage disease impact. The appropriateness of these proposals will be further scrutinized by clarifying whether high PGA in patients otherwise in remission is associated with subclinical inflammation and whether full remission is a better predictor than 3v-remission (without PGA) of a long-term good radiological outcome 5 .…”