This study compared remission rates in 5,848 rheumatoid arthritis patients from 24 countries using different definitions of remission. The overall remission rate varied substantially depending on the definition used, from 8.6% using the ACR definition to 19.6% using DAS28. Remission rates also varied considerably between countries. Regardless of the definition, factors associated with higher remission rates included male sex, higher education, shorter disease duration, fewer comorbidities, and regular exercise. The results indicate that reported remission rates need to be interpreted based on the specific definition of remission that was applied.

1. ARTHRITIS & RHEUMATISM
Vol. 58, No. 9, September 2008, pp 2642–2651
DOI 10.1002/art.23794
© 2008, American College of Rheumatology
Remission and Rheumatoid Arthritis
Data on Patients Receiving Usual Care in Twenty-Four Countries
Tuulikki Sokka,1
Merete Lund Hetland,2
Heidi Ma¨kinen,3
Hannu Kautiainen,4
Kim Hørslev-Petersen,5
Reijo K. Luukkainen,6
Bernard Combe,7
Humeira Badsha,8
Alexandros A. Drosos,9
Joe Devlin,10
Gianfranco Ferraccioli,11
Alessia Morelli,11
Monique Hoekstra,12
Maria Majdan,13
Stefan Sadkiewicz,14
Miguel Belmonte,15
Ann-Carin Holmqvist,16
Ernest Choy,17
Gerd R. Burmester,18
Recep Tunc,19
Aleksander Dimic´,20
Jovan Nedovic´,20
Aleksandra Stankovic´,20
Martin Bergman,21
Sergio Toloza,22
and Theodore Pincus,23
for the Questionnaires in Standard Monitoring of
Patients With Rheumatoid Arthritis Group
Objective. To compare the performance of differ-
ent definitions of remission in a large multinational
cross-sectional cohort of patients with rheumatoid ar-
thritis (RA).
Methods. The Questionnaires in Standard Moni-
toring of Patients with RA (QUEST-RA) database,
which (as of January 2008) included 5,848 patients
receiving usual care at 67 sites in 24 countries, was used
for this study. Patients were clinically assessed by
rheumatologists and completed a 4-page self-report
questionnaire. The database was analyzed according to
the following definitions of remission: American College
of Rheumatology (ACR) definition, Disease Activity
Score in 28 joints (DAS28), Clinical Disease Activity
Index (CDAI), clinical remission assessed using 42 and
28 joints (Clin42 and Clin28), patient self-report Rou-
tine Assessment of Patient Index Data 3 (RAPID3), and
physician report of no disease activity (MD remission).
Results. The overall remission rate was lowest
Supported by Abbott.
1
Tuulikki Sokka, MD, PhD: Jyva¨skyla¨ Central Hospital, Jy-
va¨skyla¨, Finland, and Medcare Oy, A¨a¨nekoski, Finland; 2
Merete Lund
Hetland, MD: Copenhagen University Hospital at Hvidovre,
Hvidovre, Denmark; 3
Heidi Ma¨kinen, MD: Jyva¨skyla¨ Central Hospi-
tal, Jyva¨skyla¨, Finland; 4
Hannu Kautiainen, BS: Medcare Oy, A¨a¨ne-
koski, Finland; 5
Kim Hørslev-Petersen, MD: King Christian the Xth
Hospital, Gråsten, Denmark; 6
Reijo K. Luukkainen, MD: Satakunta
Central Hospital, Rauma, Finland; 7
Bernard Combe, MD, PhD:
Hoˆpital Lapeyronie, Montpellier, France; 8
Humeira Badsha, MD:
Dubai Bone and Joint Center, Dubai, United Arab Emirates; 9
Alex-
andros A. Drosos, MD: University of Ioannina, Ioannina, Greece;
10
Joe Devlin, MD: Waterford Regional Hospital, Waterford, Ireland;
11
Gianfranco Ferraccioli, MD, Alessia Morelli, MD: Catholic Univer-
sity of Sacred Heart, Rome, Italy; 12
Monique Hoekstra, MD, PhD:
Medisch Spectrum Twente, Enschede, The Netherlands; 13
Maria
Majdan, MD: Medical University of Lublin, Lublin, Poland; 14
Stefan
Sadkiewicz, MD: Szpital Wojewodzki im. Jana Biziela, Bydgoszcz,
Poland; 15
Miguel Belmonte, MD, PhD: Hospital General de Castello´n,
Castello´n, Spain; 16
Ann-Carin Holmqvist, MD: Hudiksvall Medical
Clinic, Hudiksvall, Sweden; 17
Ernest Choy, MD, MRCP: Kings Col-
lege Hospital, London, UK; 18
Gerd R. Burmester, MD: Charite
University Medicine Berlin, Berlin, Germany; 19
Recep Tunc, MD:
Meram Medical Faculty, Konya, Turkey; 20
Aleksander Dimic´, MD,
PhD, Jovan Nedovic´, MD, Aleksandra Stankovic´, MD: Rheumatology
Institut, Niska Banja, Serbia; 21
Martin Bergman, MD: Taylor Hospital,
Ridley Park, Pennsylvania; 22
Sergio Toloza, MD: Hospital San Juan
Bautista, Catamarca, Argentina; 23
Theodore Pincus, MD: New York
University Hospital for Joint Diseases, New York, New York.
Dr. Sokka has received consulting fees, speaking fees, and/or
honoraria from Abbott, UCB, and Wyeth (less than $10,000 each). Dr.
Badsha has received consulting fees, speaking fees, and/or honoraria
from MSD, Novartis, and Servier (less than $10,000 each). Dr.
Ferraccioli has received honoraria from Bristol-Myers Squibb, Abbott,
Wyeth, Roche, and Schering-Plough (less than $10,000 each). Dr.
Choy has received consulting fees, speaking fees, and/or honoraria
from MSD, Pfizer, GlaxoSmithKline, Abbott, Schering-Plough, Wyeth,
Merrimack Pharmaceutical, Chelsea Therapeutics, UCB Celltech,
Roche, Pierre Fabre Medicament, Allergan, and Jazz Pharmaceuticals
(less than $10,000 each). Dr. Burmester has received a research grant
from Abbott for the use of ultrasound to study remission. Dr. Bergman
has received consulting fees, speaking fees, and/or honoraria from
Amgen, Genentech, and Centocor (less than $10,000 each) and from
Abbott and Bristol-Myers Squibb (more than $10,000 each). Dr.
Pincus has received consulting fees, speaking fees, and/or honoraria
from Abbott (less than $10,000).
Address correspondence and reprint requests to Tuulikki
Sokka, MD, PhD, Arkisto/Tutkijat, Jyva¨skyla¨ Central Hospital, 40620
Jyva¨skyla¨, Finland. E-mail: tuulikki.sokka@ksshp.fi.
Submitted for publication November 23, 2007; accepted in
revised form May 23, 2008.
2642

2. using the ACR definition of remission (8.6%), followed
by the Clin42 (10.6%), Clin28 (12.6%), CDAI (13.8%),
MD remission (14.2%), and RAPID3 (14.3%); the rate of
remission was highest when remission was defined
using the DAS28 (19.6%). The difference between the
highest and lowest remission rates was >15% in 10
countries, 5–14% in 7 countries, and <5% in 7 countries
(the latter of which had generally low remission rates
[<5.5%]). Regardless of the definition of remission,
male sex, higher education, shorter disease duration,
smaller number of comorbidities, and regular exercise
were statistically significantly associated with remission.
Conclusion. The use of different definitions of
RA remission leads to different results with regard to
remission rates, with considerable variation among
countries and between sexes. Reported remission rates
in clinical trials and clinical studies have to be inter-
preted in light of the definition of remission that has
been used.
Although treatments for rheumatoid arthritis
(RA) were formerly often called “remission-inducing
drugs,” long-term remission (for Ͼ1 year) was seen in
only a small minority of patients in usual clinical care
(1). Remission rates in usual clinical care are now higher
than in the past (2,3), and the clinical status of RA
patients who are treated actively in rheumatology clinics
has improved substantially compared with previous de-
cades (4–14).
Most randomized clinical trials are designed to
analyze differences between active and control treat-
ments, rather than to assess attainment of a specific
clinical status such as remission. A few trials have focused
on “tight control” of inflammation according to a pro-
tocol that guides treatment according to clinical re-
sponses. These trials have documented that in a large
proportion of patients, remission can be achieved with
methotrexate in combination with other traditional
disease-modifying antirheumatic drugs (DMARDs) and
with biologic agents.
In the FIN-RACo (Finnish Rheumatoid Arthritis
Combination Therapy) trial (15), 2-year remission rates
according to the Disease Activity Score in 28 joints
(DAS28) (16) were 68% in the combination treatment
arm and 41% in the monotherapy arm, and remission
rates according to the American College of Rheumatol-
ogy (ACR) definition (17) were 42% versus 20%, re-
spectively, in the 2 groups. In the CIMESTRA (Cyclo-
sporine, Methotrexate, Steroid in RA) trial (18),
remission rates at 2 years in the combination treatment
and monotherapy arms, respectively, were 59% and 54%
for DAS28 remission and 41% and 35% for ACR
remission. In the TICORA (Tight Control of RA) study
(19), RA remission based on a DAS score of Ͻ1.6
was achieved in 65% of the patients in the “tight
control” group and 16% in the control group. In the
BeSt (Behandelstrategiee¨n voor Reumatoide Artritis
[Treatment Strategies for RA]) study (20), RA was in
remission in 38–46% of patients in the 4 treatment arms
at the end of intervention. Thus, it appears that “tight
control” is a “remission-inducing” strategy in patients
with early RA.
There is no single “gold standard” measure for
RA disease activity. Accordingly, disease activity or its
absence (remission) is measured using various com-
posite indices such as the ACR core data set (21), the
DAS, and others. Rates of remission differ according to
these indices, and different levels have been described to
depict “true” remission (22,23).
In the present study, we compared the perfor-
mance of different definitions of remission in 5,848
patients from 24 countries who are included in the
Questionnaires in Standard Monitoring of Patients with
RA (QUEST-RA) database (24). We analyzed remis-
sion rates by country and investigated possible associa-
tions between demographic and lifestyle variables and
remission.
PATIENTS AND METHODS
The QUEST-RA program was established in 2005 to
promote quantitative assessment in usual clinical care at
multiple sites, and to develop a database of RA patients
seen in regular care in many countries. The initial design
involved assessment of 100 RA patients at Ն3 sites in differ-
ent countries. Data collection was begun in January 2005.
By January 2008, the program included 5,848 patients from
67 sites in 24 countries (Argentina, Canada, Denmark, Esto-
nia, Finland, France, Germany, Greece, Hungary, Ireland,
Italy, Kosovo, Latvia, Lithuania, The Netherlands, Poland,
Russia, Serbia, Spain, Sweden, Turkey, the United Arab
Emirates, the United Kingdom, and the United States) (24).
These 5,848 patients comprised the present study population.
All patients were assessed according to a standard protocol to
evaluate RA (25).
Clinical evaluation. Physicians completed three 1-page
forms on each patient: 1) a review of clinical features, including
classification criteria, extraarticular features, comorbidities,
and relevant surgeries; 2) information on all previous and
present DMARDs taken, their adverse events, and reasons for
discontinuation; and 3) results of a 42-joint count (26) which
included a swollen joint count (SJC) and tender joint count
(TJC), as well as a count of joints with limited motion or
deformity. The review included physician global assessment of
disease activity (MDglobal) on a 10-cm visual analog scale
(VAS) in which the physician was asked “Please mark below
DEFINITIONS OF REMISSION IN RA 2643

3. your assessment of the patient’s current disease activity,” with
“no activity” at the left end and “very active” at the right end.
The review also included the physician’s report of whether the
patient had radiographic erosions, and findings of laboratory
tests, i.e., erythrocyte sedimentation rate (ESR), C-reactive
protein level, and rheumatoid factor status.
Patient questionnaires. Patients completed a 4-page
expanded self-report questionnaire that included the Health
Assessment Questionnaire (HAQ) (27) and the multidimen-
sional HAQ (28) to assess functional capacity in activities of
daily living. Pain, patient-rated global health status (GH),
fatigue, and patient-report current disease activity (PTglobal)
(29) were assessed on a 0–10–cm VAS. Information on
duration of morning stiffness, lifestyle choices such as smoking
and physical exercise, height and weight for calculation of body
mass index (BMI), and demographic characteristics including
years of education and work status was collected (24).
Definitions of remission. The database was analyzed
for remission according to the following definitions.
1. ACR remission: 5 of 6 criteria met, including (a) no
swollen joints on 42-joint count, (b) no tender joints on 42-joint
count, (c) normal ESR (Ͻ30 mm/hour in women and Ͻ20
mm/hour in men), (d) morning stiffness Յ15 minutes, (e) no
joint pain (Յ1.0 cm on VAS), and (f) no fatigue (Յ1.0 cm on
VAS) (17).
2. DAS28 remission: DAS28 score of Ͻ2.6, calculated
using the formula
([0.56 ϫ ͱTJC28] ϩ [0.28 ϫͱSJC28] ϩ [0.70 ϫ lnESR] ϩ
[0.014 ϫ GH])
(16,30).
3. Clinical Disease Activity Index (CDAI) remission:
CDAI score of Յ2.8, from the formula SJC28 ϩ TJC28 ϩ
PTglobal ϩ MDglobal (31).
4. Clinical remission (Clin28 and Clin42): 3 of 3 criteria
for Clin28 met, including (a) no swollen joints on 28-joint
count, (b) no tender joints on 28-joint count, and (c) normal
ESR (Ͻ30 mm/hour in women and Ͻ20 mm/hour in men); or
3 of 3 criteria for Clin42 met, including (a) no swollen joints on
42-joint count, (b) no tender joints on 42-joint count, and (c)
normal ESR (Ͻ30 mm/hour in women and Ͻ20 mm/hour in
men).
5. Routine Assessment of Patient Index Data 3
(RAPID3) remission: score of Յ1.0 on the RAPID3, an index
that is based on patient self-report outcomes only and includes
HAQ physical function, pain, and GH, all normalized to 0–10,
counted together, and divided by 3 to yield a scale of 0–10 (32).
6. MD remission: no disease activity according to the
rheumatologist (MDglobal Յ0.3) (33) (3 mm was allowed for
“writing” error in MD/assistant handwriting).
Statistical analysis. Remission rates are presented as
percentages with 95% confidence intervals (95% CIs). The
unadjusted prevalence of remission according to different
definitions is presented for each country. The prevalence of
ACR and DAS28 remission adjusted for sex, age, and dis-
ease duration is also shown by country. Remission rates based
on different definitions were also calculated for females and
males according to SJC28, in arbitrary categories of 0, 1, 2–3,
and Ն4 swollen joints, and differences assessed by chi-square
test.
Kappa and Jaccard statistics (with 95% CIs) were used
to assess agreement between different remission criteria and to
study the agreement between the Clin28 and other remission
criteria. These two methods for assessing agreement were used
because kappa “total” agreement takes into account all obser-
vations (positive and negative) (a ϭ ϩ,ϩ; b ϭ Ϫ,ϩ; c ϭ ϩ,Ϫ;
d ϭ Ϫ,Ϫ ), whereas in the Jaccard method, positive agreement
is divided by all positive observations (a/[a ϩ b ϩ c]). There-
fore, the Jaccard statistic represents the probability of both
positive observations occurring together.
To study the association of remission with demo-
graphic and lifestyle-related variables, forward stepwise logistic
regression models were applied separately for each definition of
remission. The model included sex, age, disease duration, num-
ber of comorbidities, BMI (Ͻ30 mg/kg2
versus Ն30 mg/kg2
),
current smoking status (no/yes), and frequency of physical
exercise (regular exercise 1 or more times a week versus no
regular exercise). The model also included level of education.
Because of different school systems in different countries, the
highest tertile of years of education in each country was defined
as “higher education” (versus “lower education,” which repre-
sented the lowest two-thirds of years of education in each
country).
Figure 1. Unadjusted rates of remission in the QUEST-RA (Ques-
tionnaires in Standard Monitoring of Patients with Rheumatoid Ar-
thritis) study, according to different definitions. Bars show the 95%
confidence intervals. ACR ϭ American College of Rheumatology
definition of remission; Clin42 and Clin28 ϭ clinical remission as-
sessed using 42 and 28 joints; CDAI ϭ Clinical Disease Activity Index
definition of remission; MD ϭ physician report of no disease activity;
RAPID3 ϭ remission according to the patient self-report Routine
Assessment of Patient Index Data 3; DAS28 ϭ remission according to
the Disease Activity Score in 28 joints. See Patients and Methods for
details on each definition of remission.
2644 SOKKA ET AL

4. RESULTS
Demographic and clinical characteristics of the
study patients. As of January 2008 the QUEST-RA
database included 5,848 patients from 67 sites in 24
countries. The demographic characteristics were those
of a typical RA cohort: 79% of the patients were female,
Ͼ90% were white, the mean age was 57 years, and the
mean education level was 11 years (with considerable
variation between countries) (24). Data were missing for
Ͻ5% of variables, and various remission criteria could
be calculated for Ͼ95% of the patients.
Comparison of definitions of remission. Differ-
ent definitions yielded statistically significantly different
remission rates, as illustrated in Figure 1. The remission
rates calculated using the various definitions were as
follows: 8.6% for ACR remission, 10.6% for Clin42,
12.6% for Clin28, 13.8% for CDAI, 14.2% for MD
remission, 14.3% for RAPID3, and 19.6% for DAS28
remission (Figure 1 and Table 1). Overall agreement was
moderate (␬ ϭ 0.55 [95% CI 0.53–0.57]).
Remission according to different definitions, by
country. In the 24 countries, the prevalence of remission
ranged between 0 and 22% by the ACR definition, 0 and
26% by the Clin42 definition, 0 and 30% by the Clin28
definition, 0 and 35% by the CDAI definition, 0 and
39% by the MD remission definition, 0 and 35% by the
RAPID3 definition, and 0 and 41% by the DAS28
definition (Table 1). The difference between the highest
remission rate and the lowest remission rate was Ն15%
in 10 countries, 5–14% in 7 countries, and Ͻ5% in 7
countries (with low remission rates [Ͻ5.5%] according
to all definitions in the latter group of countries) (Table
1). Sex-, age-, and disease duration–adjusted remission
rates in each country according to the ACR and DAS28
definitions are illustrated in Figure 2.
Clin28 remission. Other definitions of remission
were compared with Clin28 remission. Agreement per-
centage and specificity between other definitions and
the Clin28 definition were excellent (Table 2). Sensi-
tivity was high for DAS28, CDAI, and Clin42 remis-
Table 1. Unadjusted rates of remission according to different definitions in the QUEST-RA study, by country*
Country
Definition of remission Difference
between
lowest and
highestACR Clin42 Clin28 CDAI
MD
remission RAPID3 DAS28
Greece 21.5 25.9 27.4 35.3 25.1 35.0 36.5 15.0
The Netherlands 16.3 25.9 30.4 30.6 38.5 22.7 40.8 24.5
Spain 14.2 16.7 19.9 20.1 21.7 19.3 29.7 15.5
Ireland 14.0 13.4 15.1 21.3 21.9 22.1 22.4 9.0
US 13.8 17.8 18.7 18.5 14.8 25.9 36.1 22.3
Denmark 12.3 15.2 17.4 22.2 23.2 23.8 30.9 18.5
Finland 12.3 14.0 20.5 23.8 25.3 22.0 36.6 24.3
France 11.7 13.2 17.9 14.2 13.3 17.2 29.2 17.5
Sweden 9.7 15.9 18.3 19.0 19.1 15.4 24.4 14.7
UAE 9.2 9.7 10.9 11.6 14.5 25.2 18.8 16.0
UK 8.3 8.5 9.3 13.2 20.7 11.7 18.4 12.4
Italy 8.2 10.2 11.5 10.4 10.2 3.0 7.7 8.5
Canada 8.0 10.1 12.1 17.0 24.0 13.0 19.8 16.0
Turkey 7.9 10.7 12.3 13.3 8.0 10.0 14.4 6.5
Germany 5.9 10.5 11.2 9.8 12.3 10.7 18.1 12.2
Argentina 3.7 2.0 2.9 4.5 5.5 9.3 8.4 7.3
Estonia 3.6 1.8 5.4 4.8 3.0 7.1 9.2 7.4
Russia 2.8 1.4 1.4 1.4 1.4 4.2 4.5 3.1
Latvia 2.5 1.3 3.8 3.8 1.3 3.8 5.5 4.2
Poland 1.1 1.3 1.7 2.0 2.7 5.5 3.5 4.4
Hungary 0.7 0.0 0.0 1.3 3.9 3.3 2.6 3.9
Lithuania 0.3 0.0 0.3 0.3 3.3 2.0 1.4 3.3
Serbia 0.0 0.0 1.0 0.0 0.0 0.0 0.0 1.0
Kosovo 0.0 1.0 1.0 0.0 0.0 2.0 1.0 2.0
Total 8.6 10.6 12.6 13.8 14.2 14.3 19.6 11.0
* Values are the percent of patients. QUEST-RA ϭ Questionnaires in Standard Monitoring of Patients with Rheumatoid
Arthritis; ACR ϭ American College of Rheumatology; Clin42 and Clin28 ϭ clinical remission assessed using 42 and 28 joints;
CDAI ϭ Clinical Disease Activity Index; MD remission ϭ physician report of no disease activity; RAPID3 ϭ patient self-report
Routine Assessment of Patient Index Data 3; DAS28 ϭ Disease Activity Score in 28 joints. See Patients and Methods for details
on each definition of remission.
DEFINITIONS OF REMISSION IN RA 2645

5. sion, but roughly half of those who met Clin28 remission
also met ACR, RAPID3, and MD remission (Table 2).
Agreement between Clin28 and other definitions ac-
cording to the Jaccard and kappa statistics was low to
moderate, except for excellent agreement with Clin42
(which is the extension of Clin28) (Table 2).
Remission and demographic and lifestyle vari-
ables. Regardless of the definition of remission, male
sex, higher education, shorter disease duration, lower
number of comorbidities, and regular exercise were sta-
tistically significantly associated with remission (Table
3). Older age was associated with Clin28, CDAI, and
MD remission. BMI and current smoking status were
not associated with remission in a multivariate model.
Remission and sex. Rates of remission, regard-
less of definition, were higher among men than among
women (Table 4). Among patients who had no swollen
joints, remission rates in women versus men were 21%
versus 30% (ACR), 32% versus 38% (Clin42), 38% versus
44% (Clin28), 37% versus 51%, (CDAI), 33% versus 46%
(MD remission), 25% versus 35% (RAPID3), and 42%
versus 58% (DAS28). Among patients who had 1 swollen
joint, men had significantly higher remission rates accord-
ing to ACR, DAS28, and RAPID3, but not CDAI remis-
sion (Table 4).
DISCUSSION
The results of this study show that the use of
different definitions of remission results in different
reported remission rates. ACR remission is the most
stringent. It includes signs and symptoms that are prev-
alent in an older population; we have reported previ-
ously that 85% of a community population age Ͼ50
years did not meet the ACR criteria for remission of RA
(34). The DAS28 provides the most liberal definition,
i.e., the highest remission rates, and is possibly therefore
preferred in clinical trials (22), but with this definition,
groups classified as having disease that is in remission
may include patients with considerable residual disease
activity (Table 4). A lower cut point for definition of
DAS28 remission, i.e., 2.32 rather than 2.6, has been
suggested (35). In the current patient population this cut
point yielded a remission rate of 14.3%, similar to the
rates obtained with the Clin28, CDAI, RAPID3, and
MD remission definitions.
The QUEST-RA study provides an opportunity
to compare different definitions of remission within
and between many countries with significant variation
in disease activity and remission rates. This opportunity
Table 2. Comparison of other definitions of remission with clinical remission defined using the 28-joint count*
Definition of
remission
Observer
agreement, % Sensitivity, % Specificity, % Jaccard statistic Kappa statistic
ACR 91 (90–92) 49 (47–51) 97 (96–99) 0.42 (0.39–0.46) 0.54 (0.50–0.57)
Clin42 97 (96–98) 84 (82–85) 100 (98–100) 0.84 (0.81–0.87) 0.90 (0.88–0.92)
CDAI 92 (91–93) 70 (68–72) 95 (94–96) 0.52 (0.49–0.55) 0.63 (0.60–0.67)
MD remission 89 (88–90) 59 (55–63) 93 (91–94) 0.40 (0.37–0.43) 0.50 (0.47–0.54)
RAPID3 85 (83–87) 46 (43–48) 90 (88–92) 0.28 (0.25–0.31) 0.34 (0.32–0.39)
DAS28 91 (90–92) 88 (87–89) 91 (89–92) 0.56 (0.52–0.59) 0.66 (0.64–0.68)
* Values in parentheses are 95% confidence intervals. See Table 1 for definitions; see Patients and Methods for details on each
definition of remission.
Figure 2. Sex-, age, and disease duration–adjusted rates of remission
by country in the QUEST-RA (Questionnaires in Standard Monitor-
ing of Patients with Rheumatoid Arthritis) study, according to the
ACR and DAS28 definitions of remission. Bars show the 95%
confidence intervals. See Figure 1 for definitions.
2646 SOKKA ET AL

6. has not been available until recently (24), since most
reported data on RA are based on clinical trials of
specific clinical cohorts, with data stored in separate
databases. The QUEST-RA data from 24 countries
indicate that remission rates differ notably between
countries, a phenomenon that requires further analysis,
probably including exploration of factors beyond bio-
medical ones. Nevertheless, the availability of data from
many countries from the QUEST-RA emphasizes the
generalizability of the observation that remission rates
vary considerably with the use of different definitions of
remission, except in countries in which only a very small
proportion of patients have disease that is in remission.
Some recent reports indicate that male sex is a
major predictor of remission in early RA (36,37) and
that male patients respond better than female patients
to treatments with biologic agents (38–40). In the
QUEST-RA database, RA was more likely to be in re-
mission, according to all definitions, among men.
Among patients who had no swollen joints, higher
remission rates were seen in men than in women (Table
4), indicating that among these patients the lower remis-
Table 3. Forward stepwise logistic regression models for remission according to different definitions*
Variable
Definition of remission
ACR Clin42 Clin28 CDAI MD remission RAPID3 DAS28
Female sex 0.56 (0.44–0.70) 0.65 (0.53–0.81) 0.68 (0.56–0.84) 0.55 (0.46–0.67) 0.56 (0.47–0.68) 0.53 (0.44–0.64) 0.47 (0.39–0.55)
Age 1.01 (1.00–1.02) 1.01 (1.00–1.01) 1.01 (1.00–1.01)
Disease duration 0.98 (0.97–0.99) 0.98 (0.97–0.99) 0.99 (0.98–1.00) 0.98 (0.97–0.99) 0.97 (0.96–0.98) 0.97 (0.96–0.98) 0.98 (0.97–0.99)
High education 1.28 (1.04–1.58) 1.28 (1.06–1.53) 1.45 (1.21–1.73) 1.23 (1.03–1.47) 1.50 (1.27–1.79) 1.30 (1.11–1.52)
No. of comorbidities 0.71 (0.63–0.81) 0.76 (0.68–0.85) 0.72 (0.65–0.80) 0.75 (0.68–0.83) 0.84 (0.76–0.92) 0.73 (0.67–0.81) 0.76 (0.70–0.82)
Regular exercise 1.80 (1.46–2.22) 1.60 (1.32–1.94) 1.67 (1.39–2.00) 1.71 (1.44–2.03) 1.81 (1.52–2.16) 2.21 (1.86–2.62) 2.05 (1.75–2.39)
* Only variables that remained in the final model are shown. Values are the odds ratio (95% confidence interval). See Table 1 for definitions; see
Patients and Methods for details on each definition of remission.
Table 4. Unadjusted rates of remission in female and male patients in the QUEST-RA study, by number of swollen joints*
No. of
swollen
joints
Definition of remission
ACR Clin42 Clin28 CDAI
MD
remission RAPID3 DAS28
Any
All 8.6 10.6 12.6 13.8 14.2 14.3 19.6
Female 7.6 9.9 12.1 12.8 12.7 12.3 17.1
Male 13.2 14.9 17.2 21.9 21.7 21.3 30.6
P Ͻ0.001 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ͻ0.001
0
All 23.4 33.2 39.8 40.0 36.1 27.1 46.1
Female 21.4 31.5 38.4 36.5 32.9 24.5 42.1
Male 29.5 38.2 44.0 50.7 45.6 34.7 57.5
P Ͻ0.001 0.01 0.036 Ͻ0.001 Ͻ0.001 Ͻ0.001 Ͻ0.001
1
All 2.7 0 0 9.7 13.1 16.4 19.7
Female 1.4 0 0 8.8 11.5 13.2 16.9
Male 7.5 0 0 12.9 18.6 28.0 29.6
P Ͻ0.001 0.12 0.046 Ͻ0.001 0.003
2–3
All 2.5 0 0 1.5 4.3 11.2 9.9
Female 2.2 0 0 1.2 3.9 9.2 7.4
Male 3.4 0 0 2.4 5.8 19.1 19.5
P 0.36 0.22 0.29 0.001 Ͻ0.001
Ն4
All 0.8 0 0 0 1.0 4.4 2.3
Female 0.8 0 0 0 0.8 4.2 1.8
Male 0.8 0 0 0 1.8 5.4 4.4
P 0.86 0.089 0.27 0.003
* Values are the percent of patients. See Table 1 for definitions; see Patients and Methods for details on each definition of
remission.
DEFINITIONS OF REMISSION IN RA 2647

7. sion rates in women are accounted for by other compo-
nents of the indices, such as number of tender joints,
patient self-report scores, and higher normal ESR in
women (41). Higher remission rates in men might
reflect, at least in part, sex differences in the measures
themselves, rather than true sex differences in RA
disease activity.
In addition to male sex, shorter disease duration,
higher education level, smaller number of comorbid-
ities, and regular physical exercise were associated with
remission in a multivariate model. BMI and current
smoking status were not associated with remission in this
model.
Based on a traditional rheumatology (biomedi-
cal) model, patients whose RA is in remission would not
have any signs of inflammation on careful clinical exam-
ination (42–44), and we therefore included MD remis-
sion, Clin42, and Clin28 in this study. However, exami-
nation of remission rates in different countries (Table 1)
provides somewhat confusing observations which sug-
gest that the biomedical model for remission may not be
useful in usual clinical practice.
Paulus (23) suggested that although remission
cannot be fully defined, a rheumatologist identifies it
easily on clinical examination. However, the proportion
of patients with MD remission, relative to remission
according to other definitions, ranged widely among
countries (Table 1), suggesting that physicians in some
countries are more liberal than in others and that MD
remission can not be used as a gold standard for
remission.
The Clin42 definition of remission (no tender
joints and no swollen joints, including ankles and feet)
was included in the present study on the basis of
criticism, by us and others, of the exclusion of ankles and
feet from measures of disease activity (45). However,
excluding the countries with very low overall rates of
remission, remission rates according to the Clin28 and
the Clin42 were very similar to one another in all
countries except in one, where the Clin42 remission rate
was 32% lower than the Clin28 remission rate (Table 1).
This may be explained by a large local emphasis on the
role of feet in RA (46,47), including careful clinical
examination. However, it has been shown in earlier
studies (48) and more recently (49) that a full (66- or
68-) joint count is not needed for valid assessment of RA
in groups of patients.
We regarded the Clin28 as a definition that might
provide the best reflection of remission according to a
biomedical model, and we compared other definitions
with it. However, this assumption is called into question
by the recent observation that among 107 patients with
RA who were judged by the treating rheumatologists to
be in clinical remission, almost 50% had progression
exhibited on hand/wrist magnetic resonance imaging
over 12 months (50). An “objective” clinical examination
thus appears not accurate enough to assess true remis-
sion in RA.
It is an intriguing idea to use only patient-report
data to determine remission, since these data are easy to
collect in usual care. Overall, the RAPID3 appears to
perform quite similarly to other definitions, with virtu-
ally identical prevalence of remission as that obtained
with the CDAI and MD remission definitions. Among
patients with no swollen joints, the RAPID3 classifies
RA as being in remission in the second-fewest patients
(second to ACR remission), but performs similarly to
the DAS28 among patients who have residual swollen
joints (Table 4). The inclusion of ϳ10% of patients with
2–3 swollen joints as being in remission according to the
DAS28 or RAPID3 definition is a disadvantage, and
lower cut points for remission might be considered.
Because high patient-report scores of function, pain, and
global status are more prevalent in elderly populations
(34), it might be possible to include a patient self-report
joint count in a definition of remission, possibly exclud-
ing joints with common symptoms of osteoarthritis such
as knees and fingers.
A large international multicenter database such
as the QUEST-RA may provide advantages over other
databases for studying different definitions of remis-
sion and searching for definitions that could be applied
in usual clinical settings. One of the strengths of this
collaboration is that it includes patients with adult-onset
RA, with no additional inclusion and exclusion criteria.
Therefore, the patients represent a large range of clini-
cal activity, from mild to severe (24). Furthermore,
rheumatologists who provided data were working in
real-life settings with no major benefits to collecting data
except their own interest in contributing to the rheuma-
tology community. Data were collected in different
clinical environments; traditional ways of examining and
treating patients reflect reality and may greatly vary in
the participating countries, which is also a limitation of
the study.
In conclusion, the use of different definitions of
remission yields different remission rates. Reports con-
cerning remission should include a rationale for the
choice of definition of remission, and results should be
interpreted accordingly. Furthermore, all currently used
remission definitions appear to favor men. Therefore,
2648 SOKKA ET AL

8. the rheumatology community is obliged to continue to
search for an optimal definition of remission.
AUTHOR CONTRIBUTIONS
Dr. Sokka had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy of the
data analysis.
Study design. Sokka, Hetland, Ma¨kinen, Kautianen, Pincus.
Acquisition of data. Sokka, Hetland, Ma¨kinen, Kautiainen, Hørslev-
Petersen, Luukkainen, Combe, Badsha, Drosos, Devlin, Ferraccioli,
Morelli, Hoekstra, Majdan, Sadkiewicz, Belmonte, Holmqvist, Choy,
Burmester, Tunc, Dimic´, Nedovic´, Stankovic´, Bergman, Toloza,
Pincus.
Analysis and interpretation of data. Sokka, Hetland, Ma¨kinen,
Kautiainen, Pincus.
Manuscript preparation. Sokka, Hetland, Ma¨kinen, Kautiainen,
Luukkainen, Drosos, Toloza, Pincus.
Statistical analysis. Sokka, Kautiainen.
ROLE OF THE STUDY SPONSOR
Abbott did not have a role in the study design, data collection,
data analysis, writing of the manuscript, review of the manuscript, or
decision to submit the manuscript for publication.
REFERENCES
1. Wolfe F, Hawley DJ. Remission in rheumatoid arthritis. J Rheu-
matol 1985;12:245–52.
2. Makinen H, Kautiainen H, Hannonen P, Sokka T. Frequency of
remissions in early rheumatoid arthritis defined by 3 sets of
criteria: a 5-year followup study. J Rheumatol 2005;32:796–800.
3. Listing J, Strangfeld A, Rau R, Kekow J, Gromnica-Ihle E,
Klopsch T, et al. Clinical and functional remission: even though
biologics are superior to conventional DMARDs overall success
rates remain low—results from RABBIT, the German biologics
register. Arthritis Res Ther 2006;8:R66–75.
4. Bergstrom U, Book C, Lindroth Y, Marsal L, Saxne T, Jacobsson
L. Lower disease activity and disability in Swedish patients with
rheumatoid arthritis in 1995 compared with 1978. Scand J Rheu-
matol 1999;28:160–5.
5. Pincus T, Sokka T, Kautiainen H. Patients seen for standard
rheumatoid arthritis care have significantly better articular, radio-
graphic, laboratory, and functional status in 2000 than in 1985.
Arthritis Rheum 2005;52:1009–19.
6. Sokka T, Mottonen T, Hannonen P. Disease-modifying anti-
rheumatic drug use according to the ‘sawtooth’ treatment strategy
improves the functional outcome in rheumatoid arthritis: results of
a long-term follow-up study with review of the literature. Rheu-
matology (Oxford) 2000;39:34–42.
7. Krishnan E, Fries JF. Reduction in long-term functional disability
in rheumatoid arthritis from 1977 to 1998: a longitudinal study of
3035 patients. Am J Med 2003;115:371–6.
8. Heiberg T, Finset A, Uhlig T, Kvien TK. Seven year changes in
health status and priorities for improvement of health in patients
with rheumatoid arthritis. Ann Rheum Dis 2005;64:191–5.
9. Sokka TM, Kaarela K, Mottonen TT, Hannonen PJ. Conventional
monotherapy compared to a “sawtooth” treatment strategy in the
radiographic procession of rheumatoid arthritis over the first eight
years. Clin Exp Rheumatol 1999;17:527–32.
10. Sokka T, Kautiainen H, Hakkinen K, Hannonen P. Radiographic
progression is getting milder in patients with early rheumatoid
arthritis: results of 3 cohorts over 5 years. J Rheumatol 2004;31:
1073–82.
11. Sokka T, Kautiainen H, Hannonen P. Stable occurrence of knee
and hip total joint replacement in Central Finland between 1986
and 2003: an indication of improved long-term outcomes of
rheumatoid arthritis. Ann Rheum Dis 2007;66:341–4.
12. Puolakka K, Kautiainen H, Mottonen T, Hannonen P, Korpela M,
Hakala M, et al, for the FIN-RACo Trial Group. Early suppres-
sion of disease activity is essential for maintenance of work
capacity in patients with recent-onset rheumatoid arthritis: five-
year experience from the FIN-RACo trial. Arthritis Rheum 2005;
52:36–41.
13. Krause D, Schleusser B, Herborn G, Rau R. Response to meth-
otrexate treatment is associated with reduced mortality in patients
with severe rheumatoid arthritis. Arthritis Rheum 2000;43:14–21.
14. Choi HK, Hernan MA, Seeger JD, Robins JM, Wolfe F. Metho-
trexate and mortality in patients with rheumatoid arthritis: a
prospective study. Lancet 2002;359:1173–7.
15. Makinen H, Kautiainen H, Hannonen P, Mottonen T, Leirisalo-
Repo M, Laasonen L, et al. Sustained remission and reduced
radiographic progression with combination disease modifying
antirheumatic drugs in early rheumatoid arthritis. J Rheumatol
2007;342:316–21.
16. Prevoo ML, van’t Hof MA, Kuper HH, van Leeuwen MA, van de
Putte LB, van Riel PL. Modified disease activity scores that
include twenty-eight–joint counts: development and validation in a
prospective longitudinal study of patients with rheumatoid arthri-
tis. Arthritis Rheum 1995;38:44–8.
17. Pinals RS, Masi AT, Larsen RA, and the Subcommittee for
Criteria of Remission in Rheumatoid Arthritis of the American
Rheumatism Association Diagnostic and Therapeutic Criteria
Committee. Preliminary criteria for clinical remission in rheuma-
toid arthritis. Arthritis Rheum 1981;24:1308–15.
18. Hetland ML, Stengaard-Pedersen K, Junker P, Lottenburger T,
Hansen I, Andersen LS, et al, CIMESTRA Study Group. Aggres-
sive combination therapy with intra-articular glucocorticoid injec-
tions and conventional disease-modifying anti-rheumatic drugs in
early rheumatoid arthritis: second-year clinical and radiographic
results from the CIMESTRA study. Ann Rheum Dis 2007. E-pub
ahead of print.
19. Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance
R, et al. Effect of a treatment strategy of tight control for
rheumatoid arthritis (the TICORA study): a single-blind random-
ised controlled trial. Lancet 2004;364:263–9.
20. Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, van
Zeben D, Kerstens PJ, Hazes JM, et al. Clinical and radiographic
outcomes of four different treatment strategies in patients with
early rheumatoid arthritis (the BeSt study): a randomized, con-
trolled trial. Arthritis Rheum 2005;52:3381–90.
21. Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M,
Fried B, et al. The American College of Rheumatology prelimi-
nary core set of disease activity measures for rheumatoid arthritis
clinical trials. Arthritis Rheum 1993;36:729–40.
22. Makinen H, Hannonen P, Sokka T. Definitions of remission for
rheumatoid arthritis and review of selected clinical cohorts and
randomized clinical trials for the rate of remission. Clin Exp
Rheumatol 2006;24 Suppl 43:S22–8.
23. Paulus HE. Defining remission in rheumatoid arthritis: What is it?
Does it matter? [editorial]. J Rheumatol 2004;31:1–4.
24. Sokka T, Kautiainen H, Toloza S, Makinen H, Verstappen SM,
Hetland ML, et al. QUEST-RA: quantitative clinical assessment
of patients with rheumatoid arthritis seen in standard rheumatol-
ogy care in 15 countries. Ann Rheum Dis 2007;66:1491–6.
25. Pincus T, Brooks RH, Callahan LF. A proposed standard protocol
to evaluate rheumatoid arthritis (SPERA) that includes measures
of inflammatory activity, joint damage, and longterm outcomes.
JRheumatol 1999;26:473–80.
26. Sokka T, Pincus T. Quantitative joint assessment in rheumatoid
arthritis. Clin Exp Rheumatol 2005;23 Suppl 39:S58–62.
DEFINITIONS OF REMISSION IN RA 2649

9. 27. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of
patient outcome in arthritis. Arthritis Rheum 1980;23:137–45.
28. Pincus T, Sokka T, Kautiainen H. Further development of a
physical function scale on a multidimensional health assessment
questionnaire for standard care of patients with rheumatic dis-
eases. J Rheumatol 2005;32:1432–9.
29. Stucki G, Liang MH, Stucki S, Bruhlmann P, Michel BA. A
self-administered Rheumatoid Arthritis Disease Activity Index
(RADAI) for epidemiologic research: psychometric properties
and correlation with parameters of disease activity. Arthritis
Rheum 1995;38:795–8.
30. Van der Heijde DM, van’t Hof M, van Riel PL, van de Putte LB.
Development of a disease activity score based on judgment in
clinical practice by rheumatologists. J Rheumatol 1993;20:579–81.
31. Aletaha D, Smolen J. The simplified disease activity index (SDAI)
and the clinical disease activity index (CDAI): a review of their
usefulness and validity in rheumatoid arthritis. Clin Exp Rheuma-
tol 2005;23 Suppl 39:S100–8.
32. Pincus T, Yazici Y, Bergman M, Maclean R, Harrington T. A
proposed continuous quality improvement approach to assessment
and management of patients with rheumatoid arthritis without
formal joint counts, based on quantitative Routine Assessment of
Patient Index Data (RAPID) scores on a Multidimensional Health
Assessment Questionnaire (MDHAQ). Best Pract Res Clin Rheu-
matol 2007;21:789–804.
33. Wolfe F, Rasker JJ, Boers M, Wells GA, Michaud K. Minimal
disease activity, remission, and the long-term outcomes of rheu-
matoid arthritis. Arthritis Rheum 2007;57:935–42.
34. Sokka T, Makinen H, Hannonen P, Pincus T. Most people over
age 50 in the general population do not meet ACR remission
criteria or OMERACT minimal disease activity criteria for rheu-
matoid arthritis. Rheumatology (Oxford) 2007;46:1020–3.
35. Makinen H, Kautiainen H, Hannonen P, Sokka T. Is DAS28 an
appropriate tool to assess remission in rheumatoid arthritis? Ann
Rheum Dis 2005;64:1410–3.
36. Forslind K, Hafstrom I, Ahlmen M, Svensson B. Sex: a major
predictor of remission in early rheumatoid arthritis? Ann Rheum
Dis 2007;66:46–52.
37. Mancarella L, Bobbio-Pallavicini F, Ceccarelli F, Falappone PC,
Ferrante A, Malesci D, et al, for the GISEA group. Good clinical
response, remission, and predictors of remission in rheumatoid
arthritis patients treated with tumor necrosis factor-␣ blockers: the
GISEA study. J Rheumatol 2007;34:1670–3.
38. Hyrich KL, Watson KD, Silman AJ, Symmons DP, British Society
for Rheumatology Biologics Register. Predictors of response to
anti-TNF-␣ therapy among patients with rheumatoid arthritis:
results from the British Society for Rheumatology Biologics
Register. Rheumatology (Oxford) 2006;45:1558–65.
39. Yamanaka H, Tanaka Y, Sekiguchi N, Inoue E, Saito K, Kameda
H, et al. Retrospective clinical study on the notable efficacy and
related factors of infliximab therapy in a rheumatoid arthritis
management group in Japan (RECONFIRM). Mod Rheumatol
2007;17:28–32.
40. Kvien TK, Uhlig T, Odegard S, Heiberg MS. Epidemiological
aspects of rheumatoid arthritis: the sex ratio. Ann N Y Acad Sci
2006;1069:212–22.
41. Miller A, Green M, Robinson D. Short rule for calculating normal
erythrocyte sedimentation rate. Br Med J 1983;286:266.
42. Nissila M, Isomaki H, Kaarela K, Kiviniemi P, Martio J, Sarna S.
Prognosis of inflammatory joint diseases: a 3 year follow up study.
Scand J Rheumatol 1983;12:33–8.
43. Harrison BJ, Symmons DP, Brennan P, Barrett EM, Silman AJ.
Natural remission in inflammatory polyarthritis: issues of defini-
tion and prediction. Br J Rheumatol 1996;35:1096–100.
44. Quinn MA, Green MJ, Marzo-Ortega H, Proudman S, Karim Z,
Wakefield RJ, et al. Prognostic factors in a large cohort of patients
with early undifferentiated inflammatory arthritis after application
of a structured management protocol. Arthritis Rheum 2003;48:
3039–45.
45. Landewe R, van der Heijde D, van der Linden S, Boers M.
Twenty-eight-joint counts invalidate the DAS28 remission defini-
tion owing to the omission of the lower extremity joints: a
comparison with the original DAS remission. Ann Rheum Dis
2006;65:637–41.
46. Paimela L. The radiographic criterion in the 1987 revised criteria
for rheumatoid arthritis: reassessment in a prospective study of
early disease. Arthritis Rheum 1992;35:255–8.
47. Larsen A. A radiological method for grading the severity of
rheumatoid arthritis [dissertation]. Helsinki, Finland: University
of Helsinki; 1974.
48. Fuchs HA, Pincus T. Reduced joint counts in controlled clinical
trials in rheumatoid arthritis. Arthritis Rheum 1994;37:470–5.
49. Kapral T, Dernoschnig F, Machold KP, Stamm T, Schoels M,
Smolen JS, et al. Remission by composite scores in rheumatoid
arthritis: are ankles and feet important? Arthritis Res Ther
2007;9:R72.
50. Brown AK, Conaghan PG, Karim Z, Quinn MA, Peterfy CG,
Hensor EM, et al. The relevance of sub-clinical synovitis in the
longitudinal assessment of RA: MRI-detected inflammation pre-
dicts structural progression in patients in apparent clinical remis-
sion [abstract]. Arthritis Rheum 2006;54:4034.
ADDENDIX A: THE QUEST-RA GROUP
Members of the QUEST-RA Group, in addition to the
authors, were as follows: Santiago Aguero, Sergio Orellana Barrera,
Soledad Retamozo (Hospital San Juan Bautista, Catamarca, Argen-
tina), Paula Alba, Eduardo Albiero, Alejandra Babini, Cruz Lascano
(Hospital of Cordoba, Cordoba, Argentina), Juris Lazovskis (River-
side Professional Center, Sydney, Nova Scotia, Canada), Lykke Ørn-
bjerg (Copenhagen University Hospital at Hvidovre, Hvidovre, Den-
mark), Troels Mørk Hansen, Lene Surland Knudsen (Copenhagen
University Hospital at Herlev, Herlev, Denmark), Riina Kallikorm,
Reet Kuuse, Raili Mu¨ller, Marika Tammaru (Tartu University Hospi-
tal, Tartu, Estonia), Tony Peets (East Tallinn Central Hospital,
Tallinn, Estonia), Ivo Valter (Center for Clinical and Basic Research,
Tallinn, Estonia), Sinikka Forsberg, Kai Immonen, Jukka La¨hteen-
ma¨ki (North Karelia Central Hospital, Joensuu, Finland), Maxime
Dougados, Laure Gossec (University Rene´ Descartes, Hoˆpital Cochin,
Paris, France), Jean Francis Maillefert (Dijon University Hospital,
University of Burgundy, Dijon, France), Jean Sibilia (Hoˆpital Hau-
tepierre, Strasbourg, France), Gertraud Herborn, Rolf Rau (Evange-
lisches Fachkrankenhaus, Ratingen, Germany), Rieke Alten, Christof
Pohl (Schlosspark-Klinik, Berlin, Germany), Sofia Exarchou (Univer-
sity of Ioannina, Ioannina, Greece), H. M. Moutsopoulos, Afrodite
Tsirogianni (National University of Athens, Athens, Greece), Maria
Mavrommati, Fotini N. Skopouli (Euroclinic Hospital, Athens,
Greece), Pa´l Ge´her (Semmelweis University of Medical Sciences,
Budapest, Hungary), Bernadette Rojkovich, Ilona U´ jfalussy (Poly-
clinic of the Hospitaller Brothers of St. John of God in Budapest,
Budapest, Hungary), Barry Bresnihan (St. Vincent University Hospi-
tal, Dublin, Ireland), Patricia Minnock (Our Lady’s Hospice, Dublin,
Ireland), Eithne Murphy, Edel Quirke, Claire Sheehy (Connolly
Hospital, Dublin, Ireland), Shafeeq Alraqi (Waterford Regional Hos-
pital, Waterford, Ireland), Stefano Bombardieri, Massimiliano Caz-
zato (Santa Chiara Hospital, Pisa, Italy), Maurizio Cutolo (University
of Genoa, Genoa, Italy), Fausto Salaffi, Andrea Stancati (University of
Ancona, Ancona, Italy), Sylejman Rexhepi, Mjellma Rexhepi (Pris-
tine, Kosovo), Daina Andersone (Pauls Stradina Clinical University
Hospital, Riga, Latvia), Jolanta Dadoniene, Sigita Stropuviene
(Vilnius University, Vilnius, Lithuania), Asta Baranauskaite (Kaunas
University Hospital, Kaunas, Lithuania), Johannes W. G. Jacobs,
Suzan M. M. Verstappen (University Medical Center Utrecht, Utre-
cht, The Netherlands), Margriet Huisman (Sint Franciscus Gasthuis
2650 SOKKA ET AL

10. Hospital, Rotterdam, The Netherlands), Stanislaw Sierakowski (Med-
ical University in Bialystok, Bialystok, Poland), Wojciech Romanowski
(Poznan Rheumatology Center in Srem, Srem, Poland), Witold Tlus-
tochowicz (Military Institute of Medicine, Warsaw, Poland), Danuta
Kapolka (Silesian Hospital for Rheumatology and Rehabilitation in
Ustron Slaski, Ustron Slaski, Poland), Danuta Zarowny-Wierzbinska
(Wojewodzki Zespol Reumatologiczny im. dr Jadwigi Titz-Kosko,
Sopot, Poland), Dmitry Karateev, Elena Luchikhina (Institute of
Rheumatology of the Russian Academy of Medical Sciences, Moscow,
Russia), Natalia Chichasova (Moscow Medical Academy, Moscow,
Russia), Vladimir Badokin (Russian Medical Academy of Postgradu-
ate Education, Moscow, Russia), Vlado Skakic (Rheumatology Insti-
tut, Niska Banja, Serbia), Antonio Naranjo, Carlos Rodrı´guez-Lozano
(Hospital de Gran Canaria Dr. Negrin, Las Palmas, Spain), Jaime
Calvo-Alen (Hospital Sierrallana Ganzo, Torrelavega, Spain), Eva
Baecklund, Dan Henrohn (Uppsala University Hospital, Uppsala,
Sweden), Margareth Liveborn, Rolf Oding (Centrallasarettet,
Va¨sterås, Sweden), Feride Gogus (Gazi Medical School, Ankara,
Turkey), Selda Celic (Cerrahpasa Medical Faculty, Istanbul, Turkey),
Ayman Mofti (American Hospital Dubai, Dubai, United Arab Emir-
ates), Catherine McClinton, Peter Taylor (Charing Cross Hospital,
London, UK), Ginny Chorghade, Anthony Woolf (Royal Cornwall
Hospital, Truro, UK), Stephen Kelly (Kings College Hospital, London,
UK), Christopher Swearingen (Vanderbilt University, Nashville, TN),
Yusuf Yazici (New York University Hospital for Joint Diseases, New
York, NY).
DEFINITIONS OF REMISSION IN RA 2651