Your Rheumatoid Arthritis Plan: Strive for Remission, Sidestep Relapse

Treatment with the newer drugs and positive changes in lifestyle factors indicate a hopeful outlook for people with rheumatoid arthritis (RA). According to a study review published in July 2010 in the Journal of Rheumatology, up to 42 percent of people treated for RA with combination therapies achieve complete remission (meaning they have no signs or symptoms of rheumatoid arthritis) within two years of starting therapy; up to 68 percent of those treated achieve what’s called “low disease activity,” says Ashira Blazer, MD, an instructor in the division of rheumatology at New York University School of Medicine’s Langone Medical Center in New York City.

Your chances of experiencing remission depend on a number of things, including:

  • How soon you are diagnosed after the disease begins and how soon you begin drug treatment (the sooner you’re diagnosed and treated, the higher your chances of remission)
  • How many joints are tender and swollen when you are first diagnosed (the fewer joints involved, the higher your chance for remission)
  • Your blood levels of certain proteins that indicate whole-body inflammation, namely ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein). Dr. Blazer cites data published in the September 2005 issue of Rheumatology suggesting that those with CRP blood levels higher than 20mg/dL are less likely to achieve remission than individuals with lower levels.
  • Whether you have certain inflammatory markers associated with the disease, including rheumatoid factor (RF), or the antibody known as anti-cyclic citrullinated protein (ACPA). People without RF or ACPA — those who have so-called seronegative rheumatoid arthritis — have a greater chance of remission.
  • Whether or not bony damage from RA can be seen on X-rays when you are first diagnosed (the less damage present at diagnosis, the better your chances of remission). Your physician will determine joint damage by performing periodic X-rays, looking for changes in the bones closest to the joints.

What Remission Means

Remission doesn’t mean you’re cured. It means that your symptoms (the ones you feel and the ones you don’t, such as abnormally high levels of inflammation cytokines) are almost totally alleviated, or are at such a low level that you’re able to move and function at your fullest, performing common household tasks such as dressing, cleaning, bathing, cooking, and shopping. In addition, your joints are not being further damaged by the disease.

How Do I Know if I’m in Remission?

Your rheumatologist will work with you to achieve remission, or at least the lowest possible disease activity score (DAS). In general, full remission is 15 minutes or less of morning stiffness and no pain or tenderness in the joints. (A low level of disease activity is 30 minutes or less of morning stiffness and only one or two joints that are swollen and tender.) Beyond this, remission and disease activity can be defined in several ways, says Jonathan Greer, MD, an assistant clinical professor of medicine at Nova Southeastern University in Ft. Lauderdale and the University of Miami.

Remission Criteria

Most rheumatologists follow the remission guidelines established by the American College of Rheumatology in 2011. The guidelines recommend the use of several scales that have been shown to reliably predict RA’s impact on the body.

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One of the most commonly used tools, the DAS28, measures:

• The number of swollen or tender joints your physician finds by examining you

• How active you feel your disease is on a 100-point scale

• The results of certain blood tests:

  • Erythrocyte sedimentation rate (ESR), which measures the rate at which red blood cells settle in a test tube (a fast rate indicates higher inflammation)
  • C-reactive protein (CRP), a protein the liver makes when there’s inflammation somewhere in the body

A DAS score less than 2.6 indicates remission, and a score less than 3.2 indicates low disease activity. Active disease, defined by a score greater than 5.1, may lead your doctor to make changes to your treatment.

Other valid scales include the Clinical Disease Activity Index (CDAI), the Simplified Disease Activity Index (SDAI), and the Routine Assessment of Patient Index Data 3 (RAPID3).

Treating to Target

Experts define remission and low disease activity using specific and strict criteria to help physicians treat patients to achieve remission — a practice known as “treating to target.” This approach has resulted in a higher rate of remission, as well as improved mobility over time and less damage to the joints. In an August 2016 study published in the journal Arthritis & Rheumatology, “treating to target” was shown not only to increase the remission and low-disease-activity rates, but also to improve cardiovascular disease risk factors including HDL “good” cholesterol level and function. If a person isn’t achieving low disease activity or remission according to these scales, doctors know to tailor medications in order to achieve a lower score.

Medication Is Key to Achieving Remission

The most important factor in rheumatoid arthritis remission is early and aggressive treatment with medication that improves or alleviates symptoms and halts the progression of the disease, says Dr. Greer.

Because RA is a systemic inflammatory disease, it can affect all body systems, not just joints. When untreated or undertreated, RA puts you at higher risk for developing coronary artery disease, stroke, and all cardiovascular disease, compared with those whose disease is in remission, says Greer. While even well-treated people with RA have higher cardiovascular risk both because of the disease and medication side effects when compared with age-matched healthy people, tight RA control substantially improves CV risk. Why? Effective treatment reduces the chronic inflammation and reduces the need for high doses of steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), both of which raise cardiovascular risk, says Blazer.

Although RA drugs do have side effects, the repercussions of the disease are generally much worse than the side effects associated with the medications, Greer says. “Not treating is not an option,” he states emphatically.

Stopping Disease Progression With Drugs

In addition to NSAIDs, which can reduce the symptomatic pain of RA, doctors use prescription medications to help halt the progression of the disease. Because rheumatoid arthritis is a disease of an overactive immune system, many drugs used to treat it suppress the immune system. Disease-modifying antirheumatic drugs (DMARDs), like Trexall (methotrexate), are often the first drugs many doctors choose because they improve pain and inflammation and also help slow the progression of arthritis. In addition, “biologics” are starting to gain favor. Biologics are genetically engineered drugs that block cytokines, the body’s inflammatory chemicals (such as interleukins and tumor necrosis factor). Many of the new biologic drugs are able to target each person’s unique symptoms and biomarkers, as opposed to traditional medicines that broadly reduce symptoms. Often, DMARDs and biologics are used in combination to achieve remission.

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Up Your Odds of Staying in Remission

Once you achieve remission, it’s important to stay vigilant in order to prevent a relapse. Of those who achieve remission, about half will experience a flare-up, or relapse, within six months, according to Blazer.

Why Does Relapse Occur?

The No. 1 reason people with RA relapse: They go off their medications. People start feeling good and stop their meds, but doing so does more harm than good. “It may be tempting to stop the medications once you start feeling better, but the immune system has a great memory. This is a good thing when it comes to creating antibodies for infections and why vaccines we get as children protect us for decades. But in the case of autoimmune disease, our immune system’s memory is problematic,” explains Blazer. “Once the immune system finds a target, such as your joints in RA, it will continue to pursue that target unless it is signaled to stop. The medications provide that ‘stop’ signal, and discontinuing them can cause a flare-up to ensue.”

Starting and stopping drugs can also allow your immune system to make an antibody to the medication, which renders the medication less effective or ineffective altogether. In addition, even though you may still feel all right when you go off your drugs, the disease may be affecting your joints in ways you’re not aware of. Generally, it’s better to stay on your meds, even when you’re in remission, says Blazer, though some people can lower their doses or switch to milder drugs, as long as they’re being closely monitored by a rheumatologist.

Can a person in remission ever discontinue medications? There’s no consensus among experts. Many say rheumatoid arthritis requires lifelong management with medications. Others, such as Greer, suggest there is a very small chance that an individual could cease to need medication. “It is possible for people in remission to get off medication completely, but of those that do, about 85 percent will relapse,” says Greer. Therefore, a person must be followed very closely by their doctor if they ever stop taking medication while in remission. (Those who are treated very aggressively and early with medication have the highest chance of being able to curtail drugs.)

Stopping medication is one of the top reasons people living with rheumatoid arthritis relapse.

What Else Helps People Achieve or Maintain Remission?

In addition to staying on medications and being checked regularly by a rheumatologist, the following lifestyle factors can help relieve symptoms or help prevent a relapse. Note: None of these therapies can replace medication, and they should be used only in addition to, not instead of, drug therapy, say experts.

  1. Adequate sleep Sleep supports the immune system. Anyone with an inflammatory disease like RA needs at least 7 hours of sleep and sometimes up to 10 hours to be at their best. Adequate sleep can help keep pain levels and stress in check, and stress is a factor in remission and relapses (see below).
  2. Mediterranean-style diet A study published in the journal Annals of Rheumatic Disease in March 2003 found that after two years of eating a Mediterranean diet (lots of fresh fruit, olive oil, fish, legumes, and wine, and a decrease in red meat and animal fats), people with RA experienced a decrease in inflammatory markers, an increase in functioning, and felt more energized compared with those eating a Western diet.
  3. Omega-3 fatty acids The omega 3 fatty acids EPA and DHA can help mitigate the risk of cardiovascular disease, a greater risk for those with RA. In addition, research suggests that high doses of omega 3 fatty acids (2 to 4 grams daily) can lower inflammatory chemicals in RA patients, help make RA drugs more effective and thus increase the chances for remission, says Blazer. Fish oil can also reduce the need for NSAIDs and counter heart disease risk.
  4. Tart cherry juice These fruits have a compound that is similar to the anti-inflammatory compound in NSAIDs, and they don’t carry the side effects (GI upset) that NSAIDs do. One study published in the August 2013 issue of Osteoarthritis and Cartilage found that 16 ounces (2 cups) a day consumed for 6 weeks reduced CRP levels in people with osteoarthritic knee pain. What’s more, research published in June 2010 suggests this fruit juice may aid sleep.
  5. Stress management There is a huge connection between our minds and bodies, and stress can trigger autoimmune conditions like RA, says Greer. Stress can cause the body to secrete inflammatory chemicals. Proven ways to reduce the stress response include regular meditation, deep breathing, being in nature, mindfulness-based stress reduction (MBSR) courses, and working with a counselor to learn stress-management techniques.
  6. Quitting smoking Of those who smoke, only a small percentage will experience remission, in part because smoking blunts the effects of RA drugs, says Greer. And of those who do, the vast majority will relapse if they continue to smoke. This is because cigarette smoke can alter your body’s own proteins to make them look foreign to the immune system, triggering autoimmune activity, says Blazer. Ask your doctor for a referral to a smoking cessation expert or to help you quit with the help of proven techniques such as the nicotine patch, nicotine gum, counseling, and drugs such as Chantix (varenicline).
  7. Regular exercise Aerobic and weight-bearing exercise strengthens muscles and takes the pressure off painful joints, which may be stiff and fatigued, in part because of reduced motion. Although people with RA may feel like they are in too much pain to exercise, movement is key to nipping chronic pain in the bud. “Exercise can keep patients from entering a chronic pain syndrome, where the brain gets into a pain feedback loop,” says Blazer. As many as 25 percent of people with RA develop fibromyalgia, a type of chronic pain syndrome; exercise can help lower the chances of this.
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