Clinical Course and Sustained Remission in Rheumatoid Arthritis

Abstract

Rheumatoid arthritis (RA) is an inflammatory, multisystemic autoimmune disease. It has been described as an often progressive chronic disease, characterized by severe functional decline, radiographic progression, frequent work disability and premature mortality. Efforts have been made to identify among patients with peripheral inflammatory arthritis which patients will have a benign course, with spontaneous resolution, and which will develop a chronic progressive inflammatory disabling disease if untreated. In recent years a remarkable improvement in RA patient outcome is observed. The two major approach changes that explain the better course of RA are the early diagnosis with subsequent prompt treatment initiation, and the treat to target strategy. The windows of opportunity theory sustains that in early stage of the disease autoimmunity may be reversed, and with prompt and intensive treatment even an antirheumatic drugs-free remission could be possible. Early and sustained remission became a feasible target leading to a much benign course of disease, in term of articular and systemic complication, quality of live, working disability and survival. represents different diseases from the very beginning [4]. Moreover, it has been postulated that we should reconsider whether RA should be thought of as a syndrome with multiple etiologic events [5]. Nevertheless, different cohort studies show a better outcome in recent years in RA patient [6-8]. Evidence sustains that the disease prospects of patients newly diagnosed with RA today are much better than they were decades ago, and that this seems to be the result of several changes in treatment strategies [9-11]. Therefore we may assume that at least part of the clinical course of the disease can be modified by appropriate clinical management. From Undifferentiated Peripheral Inflammatory Arthritis to Established RA Recent onset arthritis is a common complaint both in primary care settings and in rheumatologic consultations. Undifferentiated peripheral inflammatory arthritis (UPIA) diagnosis is based on the failure to satisfy classification criteria for other well-recognized rheumatic conditions such as rheumatoid arthritis, psoriatic arthritis, gout, systemic lupus erythematosus, osteoarthritis, or other infectious, metabolic, traumatic o malignant etiologies [4,12]. Its estimated prevalence is between 30% and 50% of patients presenting to the rheumatologist [13]. In some of these patients, the disease evolves into other rheumatic conditions, while in many cases disease regresses [13]. UPIA should be constantly rethought, as patients may develop a disease that can be labelled with a specific diagnosis at any time [12]. Remission rate in UPIA range from 13% [13] to 57.9%, [14] while evolution to RA according to 1987 American College of Rheumatology (ACR) classification criteria [15] range around 14% [13,14]. Nevertheless persistent disease Introduction Rheumatoid arthritis (RA) is an inflammatory, multisystemic autoimmune disease. It affects 0.5% of the population and has been described as an often progressive chronic disease, characterized by severe functional decline, radiographic progression, frequent work disability and premature mortality [1,2]. However, it is also recognized that RA has a heterogeneous spectrum varying from mild, self-limited arthritis to severe permanently active and erosive polyarthritis leading to progressive joint damage, functional disability [3] and extra-articular manifestations [4]. It remains unanswered if the wide spectrum of clinical phenotypes is determined by a different set of risk factors, or if the subsequent course ISSN: 2572-3243 DOI: 10.23937/2572-3243.1510053 Lagrutta et al. J Musculoskelet Disord Treat 2018, 4:053 • Page 2 of 6 • management may be confidently made at 12 weeks. These findings are in line with those of Green [17], and suggest that very early inflammatory disease may differ immunologically from disease of longer duration, so that intervention at this stage, prior to the development of persistence, may offer a unique opportunity for a qualitative improvement in outcome [13]. Moreover, some authors have the hypothesis that autoimmunity could even be reversed in very early phase in some patients [18]. In the timeline of disease evolution, the appearance of autoantibodies and increased levels of proinflammatory cytokines have been described years before the development of AR [16]. In this pre-disease phase, individuals with ACPA, RF and SE positivity have a significant risk of RA, especially if they have arthralgia. This phase can be transformed into definitive RA associated with the acceleration of autoimmunity, further loss of tolerance and clinical symptoms [18]. In this early stage, the disease aggressive therapy leads to disproportionate benefits and patients have a good chance of remission [10,16,18,19]. In accordance with this window of opportunity theory, the potential reversibility of autoimmunity decrease over time in RA and this alters the potential efficacy of therapies [18]. Importance of Prompt Diagnosis and Early