Remission makes its way to rheumatology

Remission was a rare event, even in the most advanced rheumatology clinics, until recent times. However, in the early 1990s, it was chosen as the treatment goal and the primary outcome measure for the Finnish Rheumatoid Arthritis Combination Therapy (FIN-RACo) trial, which can be considered the beginning of remission's way to rheumatology. In addition to remission in patients with rheumatoid arthritis, remission in patients with psoriatic arthritis is now being studied, although remission criteria for psoriatic arthritis have yet to be defined. Better treatment results with more active treatment strategies and availability of biologic agents motivate rheumatologists to monitor their patients as part of usual rheumatology care.

68% met the DAS28 remission criteria [3]. Th e fi ndings indicated that a strategy of 'tight control' appeared to be more important than a specifi c agent in the control of RA.
Subsequent studies confi rmed the importance of a 'tight control' strategy directed to 'treat to target' according to a quantitative goal. Th e TICORA (Tight Control of Rheumatoid Arthritis) trial reported a remission rate of 65% using conventional DMARDs. In the CIMESTRA (Cyclosporine, Methotrexate, Steroid in Rheumatoid Arthritis) trial, remission rates were 59% and 54% for DAS28 remission and 41% and 35% for American College of Rheumatology (ACR) remission at 2 years in the combination and monotherapy arms, respectively [4]. In the BeSt (Behandelstrategieën voor Reumatoide Artritis) study of treatment strategies for RA, 38% to 46% of patients in the four arms were in remission at the end of intervention [5].
At this time, remission rates for RA in usual clinical care are higher than in the past [6], though primarily in North America and Western Europe [7]. Similarly, the clinical status of RA patients who are treated actively in rheumatology clinics has improved substantially compared with previous decades [8,9].
A single 'gold standard' measure is not available for disease activity in RA or other infl ammatory joint diseases, and simple criteria for defi ning remission must include multiple measures. Preliminary remission criteria for RA were proposed by a committee of the American Rheumatism Association (now the ACR) in 1981 [10]. According to these criteria, remission is present if fi ve of the following conditions are met: absence of morning stiff ness, fatigue, joint pain, tenderness, and swelling and presence of normal erythrocyte sedimentation rate. However, these criteria are too stringent and are not based on real-world data; for example, mild pain is common in the population over age 50, and 85% would not meet ACR remission criteria [11]. Th e use of less stringent defi nitions of remission such as remission according to DAS28 has opened rheumatology for the concept of remission in a large number of patients [12], as shown by Saber and colleagues [1] in patients with psoriatic arthritis.
Psoriatic arthritis is a multifaceted disease. Global remission should involve the absence of peripheral

Abstract
Remission was a rare event, even in the most advanced rheumatology clinics, until recent times. However, in the early 1990s, it was chosen as the treatment goal and the primary outcome measure for the Finnish Rheumatoid Arthritis Combination Therapy (FIN-RACo) trial, which can be considered the beginning of remission's way to rheumatology. In addition to remission in patients with rheumatoid arthritis, remission in patients with psoriatic arthritis is now being studied, although remission criteria for psoriatic arthritis have yet to be defi ned. Better treatment results with more active treatment strategies and availability of biologic agents motivate rheumatologists to monitor their patients as part of usual rheumatology care.

E D I TO R I A L
*Correspondence: Tuulikki Sokka, tuulikki.sokka@ksshp.fi 1 Jyväskylä Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland Full list of author information is available at the end of the article arthritis, spondylitis, enthesitis, dactylitis, and skin disease. Fifty-eight percent, a high percentage for DAS28 remission [1], may be an overestimate compared with a real remission rate. However, no consensus about remission in psoriatic arthritis exists, and various criteria have been used to defi ne remission [13], just as various criteria were used to defi ne remission in RA [7]. In both diseases, remission has been defi ned as the treatment target [13,14].
Routine quantitative monitoring of rheumatology patients has been advocated for almost 3 decades.
However, it appears that only the availa bility of biologic agents can direct rheumatologists' interest into routine monitoring of patients' pain, func tional status, and disease activity. Th e patients of Saber and colleagues [1] were assessed every 3 months for disease activity and patient-reported outcomes. Remission is an achievable goal in rheumatology at this time, and routine monitoring of patients may make its way to rheumatology after a three-decade-long journey.
Finally, there is nothing new under the sun: Th e Health Assessment Questionnaire (HAQ) is the best predictor of the future [15] (in this case, remission). Th is observation by Saber and colleagues [1] confi rms what many reports have been showing for the past 20 years: HAQ is the best predictor of mortality, work disability, functional status, and even joint replacements and health care costs.