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American College of Rheumatology/EULAR remission criteria for rheumatoid arthritis: 2022 revision
  1. Paul Studenic1,2,
  2. Daniel Aletaha2,
  3. Maarten de Wit3,
  4. Tanja A Stamm4,
  5. Farideh Alasti2,
  6. Diane Lacaille5,
  7. Josef S Smolen2,
  8. David T Felson6
  1. 1 Division of Rheumatology, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
  2. 2 Division of Rheumatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
  3. 3 EULAR community of People with Arthritis/Rheumatism in Europe (PARE), Zürich, Switzerland
  4. 4 Division of Rheumatology, Department of Internal Medicine 3, Medical University of Vienna, Medical University of Vienna, Vienna, Austria
  5. 5 Division of Rheumatology, Department of Medicine, University of British Columbia and Arthritis Research Canada, Vancouver, British Columbia, Canada
  6. 6 Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA
  1. Correspondence to Dr Paul Studenic, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria; paul.studenic{at}meduniwien.ac.at

Abstract

Objective In 2011, the American College of Rheumatology (ACR) and EULAR endorsed provisional criteria for remission in rheumatoid arthritis (RA), both Boolean-based and index-based. Based on recent studies indicating that a higher threshold for the patient global assessment (PtGA) may improve agreement between the two sets of criteria, our goals were to externally validate a revision of the Boolean remission criteria using a higher PtGA threshold and to validate the provisionally endorsed index-based criteria.

Methods We used data from four randomised trials comparing biological disease-modifying antirheumatic drugs to methotrexate or placebo. We tested the higher proposed PtGA threshold of 2 cm (Boolean2.0) (range 0–10 cm) compared with the original threshold of 1 cm (Boolean1.0). We analysed agreement between the Boolean-based and index-based criteria (Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)) for remission and examined how well each remission definition predicted later good physical function (Health Assessment Questionnaire (HAQ) score≤0.5) and radiographic non-progression.

Results Data from 2048 trial participants, 1101 with early RA and 947 with established RA, were included. The proportion of patients with disease in remission at 6 months after treatment initiation increased when using Boolean2.0 compared with Boolean1.0, from 14.8% to 20.6% in early RA and 4.2% to 6.0% in established RA. Agreement between Boolean2.0 and the SDAI or CDAI remission criteria was better than for Boolean1.0, particularly in early disease. Boolean2.0, SDAI, and CDAI remission criteria had similar positive likelihood ratios (LRs) to predict radiographic nonprogression and a HAQ score of ≤0.5 (positive LR 3.8–4.3). The omission of PtGA (BooleanX) worsened the prediction of good functional outcomes.

Conclusion Using the Boolean 2.0 criteria classifies, more patients as achieving remission and increases the agreement with index-based remission criteria without jeopardising predictive value for radiographic or functional outcomes. This revised Boolean definition and the previously provisionally endorsed index-based criteria were endorsed by ACR and EULAR.

  • Arthritis, Rheumatoid
  • Methotrexate
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/ard-2022-223413

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    • Presented at This article is published simultaneously in Arthritis & Rheumatology.

    • Contributors All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. PS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Author note This criteria set has been approved by the American College of Rheumatology (ACR) Board of Directors and the EULAR Executive Committee. This signifies that the criteria set has been quantitatively validated using patient data, and it has undergone validation based on an independent data set. All ACR/EULAR-approved criteria sets are expected to undergo intermittent updates. The ACR is an independent, professional, medical and scientific society that does not guarantee, warrant, or endorse any commercial product or service.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.