Journal Information
Vol. 18. Issue 9.
Pages 564-566 (November 2022)
Vol. 18. Issue 9.
Pages 564-566 (November 2022)
Letter to the Editor
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How do Spanish Rheumatologists handle referral? Survey of knowledge and approach before and after a training workshop
¿Cómo manejan la remisión los reumatólogos españoles? Encuesta de conocimientos y abordaje antes y después de un taller formativo
Alejandro Balsaa,
Corresponding author

Corresponding author.
, Isidoro González-Álvarob, Raimon Sanmartíc, Hector Corominasd
a Servicio de Reumatología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
b Servicio de Reumatología, Hospital Universitario La Princesa, IIS-IP, Madrid, Spain
c Servicio de Reumatología, Hospital Universitari Clínic, IDIBAPS, Barcelona, Spain
d Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Hospital Dos de Maig, Barcelona, Spain
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Dear Editor,

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.


AbbVie was involved in the design and development of the study, as well as providing funding for the study. AbbVie was involved in the interpretation of the results, review, and approval for publication.

Conflict of interest

AB has received research support grants, consulting or speaking fees from Abbvie, Amgen, Gebro, Pfizer, Novartis, BMS, Nordic, Sanofi, Sandoz, MSD, Lilly, UCB, and Roche.

IG-A has received grants from the Instituto de Salud Carlos III during the course of the study. He has also received personal fees from Lilly and Sanofi, personal fees, and non-financial support from BMS and Abbvie; research support, personal fees, and non-financial support from Roche, and non-financial support from MSD, Pfizer, and Novartis, which may be related to the work presented.

RS is a permanent member of the advisory board of the outpatient hospital medication assessment committee (MHDA). Cat-Salut. Generalitat de Catalunya. He has received funding for conferences and projects from Abbvie, BMS, MSD, Roche, UCB, Pfizer, Gebro, Lilly, and Sanofi.

HC has received speaker’s fees from MSD, Roche, Lilly, Abbvie, Pfizer, Gebro, BMS, and Sanofi, and has participated in consultancies for Celgene, Abbvie, Amgen, Pfizer, Biogen, and Sanofi.


Loreto Carmona, InMusc, for conducting the surveys, data collection, and medical writing. This service was funded by AbbVie. The authors would like to thank all members of the Destination Referral working group.

Appendix A. Grupo de trabajo Destino Remisión (Destination Referral Working Group)

Miriam Almirall Bernabé (Hospital Vall d’Hebrón, Barcelona). Tomás Almorza Hidalgo (Hospital 12 de Octubre, Madrid). Isabel Añon Oñate (Hospital Virgen de las Nieves, Granada). Carmen Barbadillo Mateos (Hospital Puerta Hierro-Majadahonda, Madrid). Julia Bernárdez Moreno (Hospital Mutua de Terrassa). Noemí Busquets Pérez (Hospital General de Granollers). Yolanda Cabello Fernandez (Hospital SAS de Jerez de la Frontera). Rafael Cáliz Cáliz (Hospital Virgen de las Nieves, Granada). Santos Castañeda Sanz (Hospital de la Princesa, Madrid). Sonia Castell Quiñones (Parc de Salut del Mar, Barcelona). Meritxell Castellanos Duarte (Hospital de Badalona). Raul Antonio Castellanos Moreira (Hospital Clínico i Provincial, Barcelona). Miguel Ángel Doña Naranjo (Hospital Torrecárdenas, Almería). Alejandro Escudero Contreras (Hospital Reina Sofía, Córdoba). Miguel Ángel Ferrer González (Hospital Virgen de las Nieves, Granada). Noelia García Castañeda (Hospital de la Princesa, Madrid). Isabel García Hernández (Hospital Universitario Virgen Macarena, Sevilla). María José González Fernández (Instituto Universitario Dexeus, Barcelona). Eduardo Graell Martín (Hospital Parc Taulí, Sabadell). Blanca Hernández Cruz (Hospital Universitario Virgen Macarena, Sevilla). Stanislava Mandelikova (Hospital Clínico i Provincial, Barcelona). Melania Martínez Morillo (Hospital Germans Trias i Pujol, Badalona). Lourdes Mateo Soria (Hospital Germans Trias i Pujol, Badalona). Natalia Mena Vázquez (Hospital Regional Universitario de Málaga). Sonia Mínguez Blasco (Hospitalde Manresa). Rafaela Ortega Castro (Hospital Reina Sofía, Córdoba). José Luis Pablos Álvarez (Hospital 12 octubre, Madrid). Blanca Panero Lamothe (Hospital Regional Universitario, Málaga). M. José Pérez Galán (Complejo Hospitalario, Jaén). Carolina Pérez García (Parc de Salut Mar, Barcelona). Manuel Pujol Busquets (Hospital Mutua de Terrassa). Delia Reina Sanz (Consorci Sanitari Integral Moises Broggi, Sant Joan Despí). José Rey Rey (Hospital Virgen de la Salud, Toledo). Elena Riera Alonso (Hospital Mutua de Terrassa). Carlos Rodríguez Escalera (Complejo Hospitalario, Jaén). Sebastián Cruz Rodríguez García (Hospital Clínico i Provicial, Barcelona). Pablo Rodríguez Merlos (Hospital La Paz, Madrid). Montserrat Romera Baures (Hospital Bellvitge-Príncipes de España, L’Hospitalet de Llobregat). Montserrat Romero Gómez (Hospital Reina Sofia, Córdoba). Virginia Ruiz-Esquide Torino (Hospital Clínico i Provincial, Barcelona). Georgina Salvador Alarcon (Hospital Mutua de Terrassa). Clara Pilar Sangüesa Gómez (Hospital Germans Trias i Pujol, Badalona). Nuria Segales Plana (Consorci Sanitari del Maresme, Mataró). Elena Leonor Sirvent Alierta (Parc Sanitari Sant Joan de Deu, Sant Boi). José Luis Tandaipan Jaime (Hospital Mutua de Terrassa). Eva Tomero Muriel (Hospital de la Princesa, Madrid). Julia Uceda Montañés (Hospital de Valme, Sevilla). M. Carmen Vargas Lebrón (Hospital Univ. Virgen Macarena, Sevilla). Cristina Vergara Dangond (Hospital Madrid, Sanchinarro), and Beatriz Yoldi Muñoz (Instituto Univ. Dexeu, Barcelona).

Appendix B
Supplementary data

The following is Supplementary data to this article:

J.S. Smolen, F.C. Breedveld, G.R. Burmester, V. Bykerk, M. Dougados, P. Emery, et al.
Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force.
Ann Rheum Dis., 75 (2016), pp. 3-15
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Defining remission in rheumatoid arthritis. New ACR/EULAR criteria.
Reumatol Clin., 6S3 (2011), pp. S12-15
J.A. Singh, K.G. Saag, S.L. Bridges Jr., E.A. Akl, R.R. Bannuru, M.C. Sullivan, et al.
2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.
Arthritis Care Res (Hoboken)., 68 (2016), pp. 1-25
I. Gonzalez-Alvaro, C. Martinez-Fernandez, B. Dorantes-Calderon, R. García-Vicuña, B. Hernández-Cruz, A. Herrero-Ambrosio, et al.
Spanish Rheumatology Society and Hospital Pharmacy Society Consensus on recommendations for biologics optimization in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis.
Rheumatology (Oxford)., 54 (2015), pp. 1200-1209
I. Gonzalez-Alvaro, A.J. Blasco, P. Lazaro, C. Sánchez-Piedra, R. Almodovar, J. Bachiller-Corral, et al.
REDOSER project: optimising biological therapy dose for rheumatoid arthritis and spondyloarthritis patients.
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Calprotectin as a biomarker for rheumatoid arthritis: a systematic review.
J Rheumatol., 42 (2015), pp. 760-770
C. Acebes, J.L. Andreu, A. Balsa, E. Batlle, J. de Toro-Santos, F. García Llorente, et al.
Exploring the remission concept in rheumatoid arthritis with patients and rheumatologists: time for a new approach?.
Clin Exp Rheumatol., 35 (2017), pp. 816-822

Please cite this article as: Balsa A, González-Álvaro I, Sanmartí R, Corominas H. ¿Cómo manejan la remisión los reumatólogos españoles? Encuesta de conocimientos y abordaje antes y después de un taller formativo. Reumatol Clin. 2022;18:564–566.

Copyright © 2021. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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