People living with rheumatoid arthritis (RA) work hard to manage their symptoms, using a combination of medication and lifestyle approaches like food and exercise choices. For many, the ultimate goal is remission—a significant period of time when they experience little or no pain, swollen joints or fatigue due to RA. “For me, being in remission means having your daily life back,” explains Michael Kuluva, who has been living with RA for 10 years. “It’s like being in lockdown and then having everything open up again!” Here’s what you need to keep in mind about remission.
What is arthritis remission?
“When we talk about remission, what we really mean is the inflammatory part of the arthritis is completely controlled,” says Dr. Glen Hazlewood, a rheumatologist in Calgary. “The immune system is no longer attacking the joints.” Doctors and patients may have somewhat different ideas about when remission has been achieved. For some people living with RA, remission is about their lived experience with the disease, where they are dealing with few or no troubling symptoms. While physicians take this lived experience and self-reporting into account, they also use tools like ultrasound imaging of joints and blood tests to measure markers of inflammation called CRP, or C-reactive protein.
There are several different approaches a doctor may use to assess an RA patient for signs of remission. Dr. Hazlewood says one common approach involves five different assessments: the “patient global” assessment (how a patient rates their symptoms on a scale of zero to 10); the “physician global” assessment (how a doctor rates the patient’s symptoms on a scale of zero to 10); a physical assessment or imaging to detect swollen joints; an assessment to detect painful joints; and tests for blood markers of inflammation. “Those five things can be added up in different ways—essentially, you plunk those things into a formula. And there [are] different thresholds for what we consider remission,” he says.
How often does remission occur?
Remission can be tough to achieve, but it is definitely a realistic goal for many people living with RA, especially in the last decade or so with significant advances in medications and research. “For people who are recently diagnosed, 40 to 60 per cent will achieve remission within the first one to two years after diagnosis,” says Dr. Hazlewood. He adds that those who lived with untreated or undiagnosed RA for a longer time may have a harder time getting to remission due to damaged joints.
How can remission be achieved?
“We have a whole arsenal of medications we can use, and we can almost always find a medication that will work for a patient. Sometimes it's a bit of trial and error initially,” says Dr. Hazlewood. These medications can be either biologic or non-biologic and are called DMARDs (disease-modifying antirheumatic drugs). “The approach to rheumatoid arthritis treatment has really been early and rapid control of the disease. And we often use multiple medications together to get to that point and escalate rapidly. We're trying to get things under control as quickly as possible, and we [may] keep adding in medications until that's the case,” explains Dr. Hazlewood.
Diet, smoking and physical activity can also play a role for many people living with RA. For example, a 2018 study that used data from the Canadian Early Arthritis Cohort (CATCH) found that for RA patients who were receiving treatment in the first 12 months after their diagnosis, obesity in women and smoking in men were the strongest predictors of not achieving remission in that time. For Michael Kuluva, it took about six to 12 months after his initial diagnosis at age 28 to get to remission. In addition to taking medication, he limits sugary or processed foods to help keep his RA under control.
Does your treatment change once you’re in remission?
After six to 12 months of remission, you and your doctor may discuss reducing your medication. “The ideal is to find the minimum medication that can control someone's disease,” says Dr. Hazlewood, adding that this is done cautiously and slowly, perhaps with an adjustment every three to six months. This approach is not for everyone, though. “A lot of people who get into remission just never want to go back to having a flare, so they are really reluctant to reduce their medications. And that's entirely appropriate as well.”
How long does remission last?
Remission can last for months or even years. About 20% or higher of people in remission will have a flare in a given year, but most of those flares do settle down with appropriate treatment, says Dr. Hazlewood.
How can you prepare for a potential arthritis flare?
Michael Kuluva found that many of his flares are related to stressful, busy times at work. He is a fashion designer, so the demands of preparing for Fashion Week often set the stage for a flare. The solution was for his rheumatologist to temporarily increase his medication for a few weeks before an event, and then return to normal levels.
“From the physician perspective, I think having a plan in place for a flare is really helpful,” says Dr. Hazlewood. Knowing what to do and who to contact if you start having an increase in symptoms is key. He says that a doctor can give a prednisone or cortisone shot in a painful joint as well. Some patients can tell that a flare is potentially on the horizon and by paying attention to early warning signs, seeking treatment, managing their lifestyle and reducing workload and stressors, they can better mentally and physically prepare. “Just take it day by day and do the best you can,” advises Kuluva. “Each day is a new day.”