Rheumatoid arthritis (RA) is a chronic autoimmune condition where the body’s immune system mistakenly attacks its own tissues, primarily leading to inflammation in the joints. This can result in pain, swelling, and stiffness, often affecting the hands and feet. While there is currently no cure for RA, a primary goal of modern treatment is to achieve a state of remission. This article explores what remission means in RA and how it can be achieved and maintained.
Defining Rheumatoid Arthritis Remission
Rheumatoid arthritis remission describes a state where an individual experiences few to no symptoms of active disease, such as joint pain, stiffness, or swelling. For patients, this often translates to feeling very good, with minimal impact from their condition on daily life. Remission does not signify a cure; the underlying autoimmune disease remains present, but its activity is suppressed.
Doctors formally define and measure RA remission using specific criteria. The American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) developed widely accepted criteria. One common definition, known as the Boolean-based definition, requires a patient to have no more than one tender joint, no more than one swollen joint, a C-reactive protein (CRP) level of 1 mg/dL or less, and a patient global assessment of arthritis activity of 1 or less on a 0-10 scale.
Other composite indices are also used, such as the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI). The SDAI combines tender and swollen joint counts, the patient’s and physician’s global assessments, and CRP levels, with a score of 3.3 or less indicating remission. The CDAI is similar but excludes the CRP level, with a score of 2.8 or less for remission. These measures help rheumatologists confirm low or absent disease activity, guiding treatment decisions.
The Path to Achieving Remission
Achieving remission in rheumatoid arthritis often involves a medical approach known as “treat-to-target.” This strategy establishes remission, or at least low disease activity, as a therapeutic goal. It involves close collaboration between the patient and their rheumatologist, with regular monitoring of disease activity and prompt adjustments to medication if the target is not met. This approach aims to reach the desired state within 3 to 6 months of treatment initiation.
Medications known as Disease-Modifying Antirheumatic Drugs (DMARDs) are central to achieving remission by calming the overactive immune system. Conventional synthetic DMARDs (csDMARDs) like methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide are often the first line of treatment due to their effectiveness in slowing disease progression and alleviating symptoms. Methotrexate, for instance, is a frequently used initial treatment. These drugs work by broadly suppressing the immune system to reduce inflammation and prevent joint damage.
When csDMARDs alone are not sufficient, biologics or targeted synthetic DMARDs (tsDMARDs) are introduced. Biologics, such as TNF inhibitors (e.g., adalimumab, etanercept), IL-6 inhibitors (e.g., tocilizumab, sarilumab), and T-cell co-stimulation inhibitors (e.g., abatacept), precisely target specific components of the immune system involved in RA inflammation. These agents block specific cytokines or cell interactions, preventing them from driving the inflammatory cascade that damages joints. Early diagnosis and aggressive treatment significantly increase the likelihood of achieving remission and preventing irreversible joint damage.
Sustaining Remission and Medication Management
Once rheumatoid arthritis remission is achieved, the focus shifts to maintaining this state, which often involves ongoing medication management. For most individuals, remission is sustained while continuing to take medications, often referred to as “remission on medication.” Drug-free remission, where patients remain symptom-free without any RA medication, is less common and typically only achievable for a small subset of patients.
Any consideration of altering medication dosage, including tapering, must involve shared decision-making with a rheumatologist. Tapering involves a slow, monitored reduction of medication dosage, rather than an abrupt stop. This process is carefully managed to assess the patient’s response and minimize the risk of disease activity returning. Studies suggest that tapering conventional synthetic DMARDs might carry a lower risk of flare compared to tapering biologics or targeted synthetic DMARDs.
Stopping medication without medical guidance carries significant risks. Discontinuing biologics can lead to a nearly twofold increase in relapse rates for patients in remission, with approximately 57% of those who stopped experiencing a relapse compared to 29% who continued treatment. Abrupt cessation can result in severe disease flares, which can cause rapid and irreversible joint damage. Therefore, for many patients, remaining on a low, maintenance dose of medication is the safest and most effective long-term strategy to preserve joint function and overall health.
Navigating Disease Flares
Even when rheumatoid arthritis is well-controlled, individuals may experience a disease flare, which is a temporary return or worsening of RA symptoms after a period of remission. Flares can manifest as increased joint pain, swelling, tenderness, and stiffness, sometimes accompanied by systemic symptoms like fatigue. While a flare can occur without an apparent reason, potential triggers include emotional or physical stress, infections, or changes in medication.
The duration of a flare can vary, lasting from a few days to several weeks. It is important not to ignore new or returning symptoms, even if they seem mild. Prompt communication with a rheumatologist is advised when a flare occurs, particularly if symptoms are worsening or becoming more frequent. Early intervention can help regain disease control quickly and prevent long-term damage.
Managing a flare often involves a temporary adjustment to the treatment plan. This might include a short course of corticosteroids to rapidly reduce inflammation, increasing the dosage or frequency of existing DMARDs, or adding a new medication. Patients can also employ self-management strategies like rest, applying heat or cold to affected joints, and using over-the-counter pain relievers. Working closely with the healthcare team ensures the response to a flare is tailored, helping to restore remission and maintain joint health.