Michaud has received research grants from the Rheumatology Research Foundation. Please see the study for all other authors' relevant financial disclosures.
Some patients with rheumatoid arthritis still demonstrate residual symptoms despite achieving low-disease activity or remission, according to findings published in Arthritis Care & Research.
“Whether or not a disease activity treatment target is achieved, many symptoms most troublesome to people living with RA are subjective in nature, and their true impact is known only to the patients themselves and not routinely captured in disease activity scores,” Kaleb Michaud, PhD, of the University of Nebraska Medical Center, and colleagues wrote.
They added: “These concerns highlight the importance of understanding and measuring other HRQoL domains that are impacted by RA and that might be ameliorated by using therapeutic approaches employed adjunctively to a goal-oriented strategy determined solely by composite measures of disease activity.”
To assess residual symptoms, and their burden, among patients with RA who have achieved their treatment targets, as well as to evaluate the extent to which symptoms were the reason some patients missed their targets, Michaud and colleagues conducted a systematic literature review. Focusing on English-language prospective and retrospective studies, the researchers identified a total of 8,339 records published from Jan. 1, 2008, to April 18, 2018. Conference abstracts from January 2016 to April 2018 and reference lists of relevant studies were also considered.
Among the identified records, the researchers included 55 in their review. Of these, 53 were unique, and 10 were randomized controlled trials. A total of 48 of the included studies reported on patients who achieved either remission or low disease activity. These studies varied in population, treatment goals and outcomes.
According to Michaud and colleagues, the studies reported on a range of symptoms among patients who achieved treat-to-target goals. Although most studies reported mean or median
values, some reported the proportion of patients achieving a certain threshold. The proportions of patients with residual symptoms varied based on the definitions used for low disease activity or remission. However, they were more often reported among patients with low disease activity than those in remission.
The most reported outcome measures were functional disability, with 34 studies; tender or swollen joints, with 18; pain, with 17; patient global assessment, with 15; and fatigue, with 14. Few studies reported the percentage of patients achieving a specific threshold, which could then be used to easily define the presence of residual symptoms, the researchers wrote.
“Despite evidence to support adoption of a T2T paradigm in the routine management of RA, residual symptoms still occur in patients achieving LDA or remission,” Michaud and colleagues wrote. “This SLR confirms that there is an unmet need, especially with respect to improving pain, fatigue and function where possible, even when a target of LDA or remission has been met.”
“Standardized reporting in future observational studies and use of measures that inform on the interference of these symptoms in the daily lives of patients would facilitate better understanding of this issue in defined RA populations,” they added. “From a pragmatic perspective, these findings suggest that setting personalized goals for the individual in addition to the practice of T2T may inform individualized management as part of holistic care.”