The aim of rheumatoid arthritis (RA) treatment is to achieve remission, but the criteria by which to establish remission are varied, complex, and unequally stringent1, with the consequent complication of management. The main criteria are the cut-off points of composite indices (DAS28, SDAI, or CDAI), Boolean ACR/EULAR criteria, remission without treatment, or ultrasound remission2. Once remission is achieved, guidelines recommend dose reduction without discontinuing any drug (ACR3), tapering glucocorticoids initially and then biologic therapy (EULAR1), or tapering glucocorticoids (not classic DMARDs) and establishing a biologic therapy dose reduction plan (SER4).

Two years ago, we set out to analyse rheumatologists’ knowledge regarding RA remission and its influence on therapeutic management in the outpatient setting. The rheumatologists completed a two-fold survey (Appendix B. Supplementary Material) before and 3 months after attending four scientific workshops on remission and management of patients in remission (including the RedoSER tool)5. Respondents were deemed to have elevated knowledge when ≥70% answered correctly; a 10-point increase or decrease in correct answers before and after the workshop implied variation.

The results indicated that Spanish rheumatologists possess adequate knowledge of remission (prior to the workshop, at least 70% answered 67% of the questions correctly) and that a very high percentage of these specialists consider that the assessment of remission should include imaging, patient perspective, and biomarkers. Remission is largely evaluated by means of the DAS28 or its components and very little using imaging or PRO (patient-dependent variables). Especially noteworthy is the similarity of the responses and the scant change of opinion following the workshops. The only two remission questions that changed were the inclusion of seroconversion in the definition (change from 14% to 29%) and the use of the CDAI (change from 22% to 38%) (Appendix B. Supplementary material).

As regards management once remission is attained, the factors the rheumatologists valued most to decide whether or not to lower the dose of biologic therapy in patients in remission are: previous failure of biologics, poor prognostic factors, presence of Power Doppler signal, monotherapy, and being on glucocorticoids. Some Spanish rheumatologists use ultrasound in certain cases to reduce biologics, but do not generally use drug levels or the RedoSER tool. The only remission management questions that changed after the workshops had to do with the importance given to low-dose glucocorticoids, the presence of high activity at the time of biologic initiation, and disease duration <1–2 years.

The main changes in decision-making following the workshops were an increase in the use of ultrasound to determine a downward titration of biologic dose, and increased use of the RedoSER tool (unknown to 54%). According to rheumatologists’ comments, this should include, among others, the risk of infection, drug or antibody levels, and calprotectin, a biomarker that correlates positively with inflammatory activity and increased radiographic progression6 (Appendix B. Supplementary material).

Despite its limitations, this work provides interesting new insights into rheumatologists' doubts surrounding remission, its influence on therapeutic decision-making, and the need to individualise the therapeutic target during remission7. Finally, the workshops have contributed to increased the use of ultrasound and RedoSER for decision-making and brought about changes in motivation for lowering doses.