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TALK OVER RA 2023 – A Global Perspective on Remission with RA – Brazil

Chronic Eileen

TALK OVER RA – A Global Perspective on Remission with RA – Brazil

 

Dr. André Luiz Luquini Pereira

MD, PhD Student – Department of Experimental Medicine, Faculty of Medicine, University of British Columbia

André is a Rheumatologist who completed his medical degree and residencies in Internal Medicine and Rheumatology in State University of Campinas in Brazil. He is pursuing a Doctor of Philosophy in Experimental Medicine degree at the University of British Columbia and working as a Research Assistant under the supervision of Dr. Diane Lacaille. André has been involved with qualitative research and expert judicial examinations in occupational medicine. He is dedicated to writing in a plain language about rheumatic diseases on his professional website, blog and social media profiles.

What is remission?

A: Remission is when inflammation is under control, and not damaging the joints anymore. The tricky thing is that inflammation does not disappear as magic, and there is something we call “subclinical inflammation” when the damage to joints keeps happening despite the patient may not feel any pain nor present any sign of inflammation (swollen joints, for example) during the physical examination. That’s why lab tests and imaging are also important to determine if the disease activity is under control or not.

The term remission is used to describe times when a disease, despite incurable, is out of activity, therefore is not causing any damage to the patient. Our goal is always to achieve remission as early as possible and keep it for as long as possible, ideally forever.

Is there a one size fits all for remission?

A: Not really, but we have some international guidelines. There are criteria for remission which were defined by research among large populations, but it includes some variability. International boards of specialists make guidelines based on these studies, so that researchers can measure the effect of drugs and rheumatologists can guide their decisions on better evidence. But patient individual evaluation is always necessary. These criteria usually involve symptoms (reported by patients and by their physicians’), signals (physical exam), imaging (ultrasound, x-ray, etc.) and lab tests (CRP).

Can you tell by bloodwork someone is in remission?

A: Bloodwork gives valuable clues, but they are more useful when used along other sources of information than alone. Some types of arthritis take longer to show up in lab tests, and some just don’t. Besides, lab tests are not specific for disease activity, and they could come positive in other health problems, such as viral or bacterial infections.

Can you tell by bloodwork someone is in remission?

A: Bloodwork gives valuable clues, but they are more useful when used along other sources of information than alone. Some types of arthritis take longer to show up in lab tests, and some just don’t. Besides, lab tests are not specific for disease activity, and they could come positive in other health problems, such as viral or bacterial infections.

Does lifestyle play a role in remission?

A: Yes, for sure. We know form population studies that smoking and obesity are huge obstacles to achieving and keeping remission, as well as stress.

How long does remission typically last? What causes someone to fall out of remission?

A: It depends. It works as a battle between starters and stoppers. So, we expect that people who smoke, eat unhealthy food, and don’t have a regular routine of exercise are at higher risk of flares. Also, patients exposed to infections, which trigger the immune system, leading to auto-immune activity. Lastly, patients who stop taking their medication (due to low adherence to the treatment, problems with access to medication or side effects) are also at high risk.

Who has a higher chance of remission – Seropositive or seronegative?

A: Patients with seronegative RA usually have a delay in their diagnosis, so they might present initially with more severe inflammation than seropositive patients. On the other hand, seropositive patients usually have higher risk for severe presentations of the disease, such as vasculitis (inflammation of blood vessels) and bone erosions.

What comorbidities get in the way of remission?

A: Obesity, infections, smoking, and mental health problems.

Can diet alone put someone into remission?

A: No. Even mild inflammation might need higher doses of medication to induce remission; then, once it is achieved, the rheumatology will plan to shift to a safer drug and/or taper down the dose according to the response to treatment. Diet is an important ally to keep remission, but relying only on diet to induce remission is dangerous, and if the interval of visits to the rheumatologist are too long, there is even the risk of bone erosions and joint deformities. In Brazil, I have followed a patient who used just homeopathy and “anti-inflammatory diet” for 2 years, when followed by another physician, painless due to low dose corticosteroids, but presented to me in her first visit with many erosions on the x-ray of hands and feet.

Can you still have pain, fatigue or cognitive dysfunction and be in remission?

A: Yes. These symptoms can be interpreted as late consequences of the inflammatory process. Pain could be explained by joint damage and deformities as a reaction to inflammation (aka secondary osteoarthritis), or an increase in brain sensitivity to pain, as it happens in fibromyalgia. Inflammation is a situation of stress and requires the use of a large amount of energy and proteins from the body. It creates an internal environment full of substances that are toxic to the brain cells, including cortisol. Over time, it is expected that theses symptoms decrease, unless they have become permanent damage, which is uncommon.

Can you stop medication if you reach remission? 

A: Any decision on your treatment plan must be made together with your rheumatologist. Remission means your treatment was enough to lead you to the desired safe place, which you don’t want to leave. We love to decrease the dose of medications, but we must be careful always. 

Are remission rates increasing?

A: Yes, advancements in treatment, especially b-DMARDS have shown great improvements on induction and duration of remission in RA.

What are some important questions patients can ask their rheumatologist around remission?

A: Planning about interval between visits, bloodwork, imaging, and decisions on decreasing drug doses, shifting drugs, vaccines, prevention of infections, and conduct in case of a flare.

Is remission more common in males or females?

A: RA is more common in women than men. It tends to start earlier and be more severe in women than men. A study from Switzerland found that men had higher odds of reaching remission than women in their sample, probably due to early escalation to bDMARDS or tsDMARDS.

Ref:

Is remission more common in younger or older people?

A: Old age at diagnosis of RA have been associated with lower response to bDMARDS and lower rates of remission, but there are conflicting findings in the literature due to the usage of different instruments to measure remission. 

Ref: 

Early and effective treatment is important for those with RA. For many patients it takes time to find the right medication for us, for those that it takes years to, can we still reach remission?

A: Yes, definitely! Strategies as “Treat to Target” are fundamental to avoid wasting time in RA, which means more damage to the cartilage. There might not be such a thing as “the right medication for me forever”, but the right plan for monitoring over time whether the drug is still working for me or not, and finding good alternatives if necessary. Research in RA is heated and will keep evolving.

Is there anything else you feel is important for patients to know?

A: Self-awareness makes all the difference. Differentiating (and reporting accordingly) pain related to inflammation from pain due to other causes such as overuse of the joint or muscle stiffness due to cold weather help the rheumatologist to take best decisions on treatment.

Download The Talk Over RA Discussion Guide

TalkOverRA is a platform that aims to empower people living with rheumatoid arthritis to advocate for themselves and their healthcare needs. It provides resources, community support, and tools to help individuals communicate effectively with their doctors and healthcare providers. The campaign emphasizes the importance of self-advocacy and provides tips for assertive communication and asking the right questions.

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