Clinical Remission Does Not Always Mean Imaging Remission in Rheumatoid Arthritis

A new study of patients with rheumatoid arthritis (RA) in Korea has shown that only about half of patients with RA who attained clinical remission were also in imaging remission.

Patients with rheumatoid arthritis (RA) may still have progression of radiographic joint damage despite being in clinical remission, regardless of the definition used for remission. A new study of patients with RA in Korea has shown that only about half of patients with RA who attained clinical remission were also in imaging remission.

The researchers analyzed 97 patients with RA who had attained clinical remission based on the Disease Activity Score-28 for Rheumatoid Arthritis with ESR (DAS28-ESR). They performed an ultrasound on 16 joints and 2 tendons for all the patients.

The patients had all attained clinical remission for more than 6 months, and 78 (80.4%) patients were rheumatoid factor (RF) positive and 82 (92.1%) patients were anti-cyclic citrullinated peptide (anti-CCP) positive. Only 20 (20.6%) patients were treated with biologics.

Only 51.5% (50/97) of patients who had attained clinical remission according to DAS28-ESR also achieved imaging remission, but the results were similar for other remission criteria. The remaining patients had a positive Power Doppler (PD) US, with PD detected most often in the right radiocarpal joint (41.2%).

In terms of other clinical remission criteria, 55.8% who were in remission based on the Simple Disease Activity Index (SDAI), 57.7% based on the Clinical Disease Activity Index (CDAI), and 55.1% based on the American College of Rheumatology/European League Against Rheumatism Boolean remission criteria also achieved imaging remission.

The patients who reached both imaging and clinical remission had lower evaluator global assessment scores (P < .001, 95% CI, –5.60 to –2.27) and lower clinical disease activity scores (P = .025, 95% CI, –1.47 to –0.33 for SDAI; P = .002, 95% CI, –1.47 to –0.33 for CDAI). Patients in clinical remission but who did not reach imaging remission were more likely to have higher active joint counts, patient global assessments, and Health Assessment Questionnaire scores. The patient who did not attain imaging remission were also more likely to use more nonsteroidal anti-inflammatory drugs.

Since the study was retrospective in nature, it is not possible to demonstrate a causal relationship between variables, the authors noted. In addition, there could be some selection bias, because only patients who had achieved clinical remission and received an US were enrolled.

“…physicians should carefully evaluate patients who have attained clinical remission,

particularly when considering whether to reduce or withdraw a specific therapy,” the authors concluded.


Wan Chung S, Young Choi J, Hoon Lee S, et al. Predicting imaging remission in rheumatoid arthritis: a case-control ultrasound study. J Korean Med Sci. 2020;35(31):e260. doi:10.3346/jkms.2020.35.e260

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