People who have rheumatoid arthritis (RA) often undergo an unpredictable cycle of remitting and relapsing. They can go for weeks at a time with no symptoms, and then endure pain and other symptoms severe enough to keep them home from work.
True remission from RA happens very infrequently, according to Dr. John Klippel, from the Arthritis Foundation. "I think one has to be honest and say that the chance of remission is quite small. We're simply trying to control the disease," he says.
The American College of Rheumatology has developed a set of guidelines for remission of RA. At least five of the following six conditions must be absent for at least two months:
inflammatory joint pain
morning stiffness exceeding 15 minutes
soft tissue swelling in the joints or tendon sheaths
further damage to the bone or cartilage of joints on X-ray
a sedimentation rate (ESR) above 30 in women or above 20 in men. An ESR is the measure of how rapidly red blood cells settle out of the blood; higher rates indicate increased inflammation.
This definition of remission, however, was published in 1981, and most rheumatologists feel that it's flawed. "I think a more rigid definition would be, 'there's no evidence of joint swelling or discomfort, and the patient is receiving no medications,'" says Dr. Klippel. "That would be a true remission. And that does occur rarely."
Aggressive treatment first
Even though true remission is rare, advances in RA research are allowing patients to live more fulfilling, less painful lives. The consensus of most experts is that early aggressive treatment is the ideal way to manage RA.
Traditionally, RA patients were treated by the "pyramid approach." Doctors started their patients out with the least toxic medications. If those didn't work, the rheumatologist would move the patient up to a second line of pharmaceutical therapies. Doctors took this approach so they could, if possible, spare their patients the toxic side effects of second-line treatments.
"We've accepted that the pyramid approach is not the right way to treat this disease," says Dr. Klippel. "This is a serious disease that becomes chronic, and damage to the joints occurs very early in the disease. Now we talk about 'inverting the pyramid,' which means you start with the most aggressive therapies."
But what about the toxicity of these medications? According to Dr. Klippel, aggressive therapies are the lesser of two evils. "Failing to treat RA in and of itself is very harmful to the patient, so one has to balance safety with what the disease itself is going to lead to," he says. "We believe that the earlier a diagnosis is made and the earlier treatment is instituted, the greater the chance for a successful outcome, including remission."
Remission of RA isn't fully understood, but rheumatologists do believe that patients are most likely to go into remission early in the disease. "It's much less likely to occur the longer a person has the disease," says Dr. Klippel. One reason, he says, is because the patient tends to be more resistant to therapies once the disease has advanced.
In addition, RA progresses rapidly, and deterioration of joints happens early on in the disease. Doctors prefer to help patients fight only the disease, not the disease plus joint damage. Even if patients go into remission from RA, their quality of life is limited if they are already disabled because of joint damage.
Managing the disease
Patients with RA are now told to exercise. Just 15 years ago, Dr. Klippel says, "it was standard teaching that patients with RA not exercise. I think we see now how terribly important physical therapy and exercise are. If a patient is involved in a program of exercise, then when remission does occur, they'll already have normal muscle strength and normal joint movement."
The best advice an RA patient can take is to work with his or her rheumatologist to find an ideal mix of medication, management and exercise.
"The most important thing an RA patient can do to increase their chances of remission is to see their rheumatologist, get an early diagnosis and begin aggressive treatment," says Dr. Klippel.
"Right now, remission isn't possible for the vast majority of people with RA, yet that's the hope," he says.