Ultrasound-detected subclinical inflammation was better reflected by the disease activity score (DAS-28) in patients with suspicion of inflammatory arthritis compared to established rheumatoid arthritis

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments.

OBJECTIVE

To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2).

DATA SOURCES

Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts.

STUDY SELECTION

Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients.

RESULTS

Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant.

LIMITATIONS

The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment.

SUGGESTED RESEARCH PRIORITIES

Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice.

CONCLUSIONS

Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016042402.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Real benefits of ultrasound evaluation of hand and foot synovitis for better characterisation of the disease activity in rheumatoid arthritis

Objectives

Optimal management of rheumatoid arthritis (RA) depends on accurate evaluation of disease activity. Foot synovitis is not included in the most used RA outcome measure (DAS-28 score). The aim of this study was to investigate how musculoskeletal ultrasound (MSK-US) examination of hand and feet correlate with the disease activity score (DAS-28 score). We also explored whether performing MSK-US assessments of hands alone compared with hands and feet underestimates the disease activity in RA.

Methods

This is a real-life cross-sectional study of 101 patients (51 with RA and 50 with other musculoskeletal conditions) with inflammatory small joint pain, who underwent MSK-US examination of hands and feet.

Results

MSK-US-detected hand synovitis was found in 18/51 (35.3%) RA patients and 16/50 (32%) of those with other musculoskeletal conditions (p = 0.96), while foot synovitis was detected in 18/51 (35.3%) and 12/50 (24%) patients, respectively (p = 0.78). DAS-28 did not correlate with any of the US outcome measures in patients with RA. Six out of 13 (46.1%) RA patients in remission, 7/14 (50%) with low disease activity and 18/32 (56.2%) with moderate disease activity (according to DAS-28 definition) had active synovitis as assessed by the MSK-US examination of their hands and feet. MSK-US-detected synovitis led to treatment escalation in 26/51 (51%) RA patients.

Conclusion

This study emphasises that MSK-US examination of hands and feet has led to optimised management of the majority of RA patients, which would have not been possible otherwise, because of the lack of correlation between DAS-28 assessment and MSK-US outcomes.

Key Points

• The most used disease activity score in rheumatoid arthritis (DAS-28) did not correlate with US outcome measures derived from hands and feet examination.

• DAS-28 did not differentiate between RA patients with subclinical active synovitis versus well-controlled disease on US.

• As a result of US examination of the hands and feet, 51% RA patients had their immunosuppressive treatment optimised.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06187-8) contains supplementary material, which is available to authorized users.

Comparative Assessment of Hand Joint Ultrasound Findings in Symptomatic Patients with Systemic Lupus Erythematosus and Sjögren's Syndrome: A Pilot Study

Systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (SS) can be associated with inflammatory arthritis, which is underdiagnosed by clinical examination. The aim of this cross-sectional, observational study was to compare, for the first time, the ultrasound (US)-detected joint abnormalities in these two diseases and to define the role of US in patient management. Participants had SLE (n = 18) and SS (n = 23), symptoms of hand joint pain and no previous diagnosis of arthritis. Data on disease activity, duration, damage scores, inflammatory and serologic markers, treatment and clinical and ultrasound parameters (derived from the assessment of 902 joints) were analysed and correlated using descriptive statistics, correlation tests and regression models. Subclinical synovitis/tenosynovitis was detected in 44.4% of SLE patients and 21.7% of SS patients (p = 0.23). There was no significant correlation between either the total Power Doppler score or the total grey-scale score and disease activity scores (British Isles Lupus Assessment Group index and European League Against Rheumatism Sjögren's syndrome disease activity index). Both damage scores (Systemic Lupus International Collaborating Clinics index and Sjögren's syndrome disease damage index) correlated with the total grey-scale synovitis score. Significant proportions of the participants with SLE and SS had erosions (55.6% and 34.8%, respectively, p = 0.184) and osteophytes (61.1% vs. 60.9%, p = 0.98) in at least one joint. The lack of correlation between disease activity scores and US outcome measures indicated their limitations in diagnosing subclinical synovitis in SLE and SS patients. Future research is needed to determine if the development of erosions could be prevented by early diagnosis and prompt treatment of inflammatory arthritis associated with SLE and SS.

Gum Arabic Fibers Decreased Inflammatory Markers and Disease Severity Score among Rheumatoid Arthritis Patients, Phase II Trial

Background

Rheumatoid arthritis (RA) is autoimmune inflammatory disease that attacks the synovium of the joints. Both TNFa and interleukin-1 play crucial roles in the pathogenesis of RA. Gum Arabic (GA) is gummy exudates from Acacia senegal tree. Gum Arabic fermentation by colonic bacteria increases serum butyrate concentrations, so it is considered as prebiotic agent. Gum Arabic (GA) has anti-inflammatory activity through its derivative butyrate. To the best of our knowledge, this is the first study conducted to investigate GA intake on inflammatory markers among RA patients.

Patients and Methods

This is clinical trial phase II in which 40 patients were enrolled aged 18 to 70 years. Patients received 30g/day GA for 12 weeks. TNF α, ESR, and complete blood count were measured and DAS-28 was calculated before and after regular GA consumption. Study was approved by the Ethical committee of National Medicines and Poisons Board.

Results

This study showed significant decrease in level of serum TNF α (p value 0.05) [95% CI, 0.65 -16.5], ESR (p value 0.011) [95% CI, 2.6 -18.89], and number of swollen and tender joints in RA patients after 12 weeks of GA intake which reflected as significant decrease in disease severity score DAS 28 P.V:0.00 [95% CI, 1.25 -1.99]. On the other hand, GA had trivial change in blood indices.

Conclusion

Gum Arabic has favorable immune modulator effect on rheumatoid arthritis. It can be utilized in clinical practice as adjuvant therapy.

Trial Registration

This trial was registered with ClinicalTrials.gov Identifier: NCT02804581 Registered at 19 June 2016, prospective registration.

Clinical significance of serum total oxidant/antioxidant status for the disease activity in active rheumatoid arthritis

Background: Oxidative stress has been considered as an important pathophysiologic factor involved in development of rheumatoid arthritis (RA). The purpose of this study was to evaluate total serum oxidant/antioxidant levels in patients with active RA and analyze its significance in disease activity. Methods: A total of 112 patients with active RA and 52 healthy controls were enrolled. Serum total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI) were measured, and baseline characteristics were recorded. The DAS-28 scores were calculated as indictor of disease. Univariate analysis and multivariate logistic regression and receiver operating characteristic curve analyses were used to evaluate significance of TOS, TAS and OSI for indictor of disease of RA. Results: Both mean TOS (7.54±3.21 VS 5.73±2.81, P<0.05) and OSI (0.37±0.21 VS 0.23±0.16, P<0.05) of active RA patients were significantly higher than that of the controls whereas mean TAS of RA patients were remarkably lower than that of the controls (2.18±0.98 VS 2.52±0.81, P=0.031). In univariate analysis, OSI, TOS, ESR, CRP, CCP and RF were significantly correlated to the disease activity of RA. Patients with high disease activity (DAS-28>5.1) had significantly higher mean TOS (8.32±3.81 VS 5.88±3.12, P<0.05) and OSI (0.39±0.18 VS 0.25±0.11, P<0.05) than that of RA with low-moderate disease activity. OSI also was confirmed as an independent predictive indictor for disease activity of RA in multivariate analysis. Conclusions: Serum OSI level represents a useful indictor for disease activity in active RA patients, thereby helping the clinician to plan more appropriate therapeutic strategies.