Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.

Near Misses of ACR/EULAR Criteria for Remission: Effects of Patient Global Scores on the Boolean and Index Based Definitions.

Studenic1,  Paul, Smolen2,  Josef, Aletaha1,  Daniel

Medical University of Vienna, Vienna, Austria
Medical University of Vienna and Hietzing Hospital, Vienna, Austria


The ACR/EULAR criteria allow definition of remission by two means: the Boolean approach requires swollen and tender joint counts (SJC, TJC), as well as C-reactive protein (CRP in mg/dL) and patient global assessment (PGA in cm) to be <=1; the index based definition requires the Simplified Disease Activity Index (SDAI, linear sum of SJC, TJC, CRP, PGA, and physician global (MDGA)) to be <=3.3. It has been argued that high PGA, if unrelated to RA disease activity, may prevent patients from fulfilling these criteria. We aimed to quantify the relevance of PGA in the definition of remission by the new ACR/EULAR criteria in a patient cohort from clinical practice.


We identified all visits of RA patients from an observational, prospective RA outpatient database. We investigated the proportion of patients who fulfilled only 3 of the 4 required Boolean criteria. Among those, we identified the proportion of patients who did not reach the criteria because of PGA, SJC, TJC or CRP.

We also looked at the proportion of patients fulfilling the index based definition (which allows scores of some variables to be >1 through compensation by other variables with lower scores), but who did not achieve Boolean criteria because of PGA.

In a next step we estimated the impact of PGA that is potentially unrelated to RA disease activity (e.g. related to secondary fibromyalgia) as a reason for failure to classify as remission. To this end, we investigated the disconnect of PGA and MDGA, by identifying those who were rated by the MD as <=1cm or not.


We identified 8242 visits of 794 RA patients (81% female, 68% rheumatoid-factor (RF) positive, mean disease duration: 7.6 years). Four of five (82%) of these patients had at least one visit, where they fulfilled just 3 of the 4 required Boolean criteria: among those, PGA was the major reason for not achieving the criteria (53%; n=344; mean PGA=3.3cm), followed by SJC (21%), CRP (16%), and TJC (10%). Almost 1 in 4 of the patients (23.5%) who failed the Boolean criteria because of PGA fulfilled the index based definition of remission.

238 patients (69.2%) with Boolean criteria failure due to PGA had a disconnect of PGA and MDGA (i.e. PGA >1 & MDGA <=1cm; mean disconnect: 2.8 cm). One third (31.9%) of those patients did fulfill the index based remission criteria. These patients showed significantly lower pain, PGA (mean PGA=1.7cm) and less disconnect of PGA and MDGA, than those not fulfilling index based criteria (mean PGA=3.7cm). Similar results were obtained when using the Boolean- and index-based definitions for clinical practice which exclude CRP from the respective formulae.


The majority of patients who fail to reach the Boolean definition of remission due to PGA are assessed as <1cm on the physician global. By means of the index based criteria, one third of these patients were classifiable as being in remission, because a slight elevation of the PGA above 1 was compensated by other variables in the index being <1. Thus PGA elevations unrelated to RA disease activity may need to be considered in clinical practice in patients who fail to classify as remission by both, the Boolean and, to a somewhat smaller extent, the index based criteria.

To cite this abstract, please use the following information:
Studenic, Paul, Smolen, Josef, Aletaha, Daniel; Near Misses of ACR/EULAR Criteria for Remission: Effects of Patient Global Scores on the Boolean and Index Based Definitions. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :328

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