Ultrasonography is a potent tool for the prediction of progressive joint destruction during clinical remission of rheumatoid arthritis

Assessment of disease activity with simplified joint ultrasonography method in rheumatoid arthritis patients

Background/Aim: Ultrasound (US) is a highly useful tool for assessing the disease activity of rheumatoid arthritis (RA). On the other hand, examining all joints could be time-consuming and unfeasible. Defining the number of joints and which joints should be tested is essential to accurately measuring RA activity. Several simplified US methods are undergoing development for this purpose. The aim of this study was to assess the correlation between simplified 12-joint US findings and physical examination findings/disease activity in RA patients. Methods: This cohort study included 62 RA patients who had been undergoing treatment for at least three months. Multiplanar grayscale images and power Doppler (PD) of the 12 joints (bilateral elbow, wrist, second and third metacarpophalangeal [MCP] joints, knee, and ankle) were acquired and compared with clinical assessments. Disease activity was assessed using the clinical disease activity and simplified disease activity indices and disease activity score-28 (CDAI, SDAI, and DAS28, respectively). Synovial effusion, synovial proliferation, and PD US scores were calculated for 12 joints. Correlations between US scores and disease activity, clinical examination, and acute phase reactants were assessed. Results: The number of joints with PD activity and US total and US synovial proliferation scores showed weak correlations with clinical activity scores (r = 0.25, r = 0.26, and r = 0.28 for SDAI and r = 0.23, r = 0.26, and r = 0.28 for DAS28, respectively). The CDAI did not present any statistically significant correlations. The agreement between US findings and clinical joint examination was generally weak. PD activities of the second MCP joints (r = 0.84, P < 0.01) and knees (r = 0.42, P < 0.01) mostly correlated with clinical examination although it was weakly correlated at the third MCP (r = 0.152) and wrist (r = 0.148), and not correlated at the elbow (r = 0.125). Conclusion: The weak correlation between US findings and clinical examination/disease activity suggests that clinical examination alone may not be sufficient to determine joint inflammation and disease activity. US could provide a more accurate assessment of RA patients and aid in medication selection.

Positive rate and prognostic significance of the superb microvascular imaging signal in joints of rheumatoid arthritis patients in remission with normal C-reactive protein levels and erythrocyte sedimentation rates

PURPOSE

This study aimed to evaluate the positive rate and prognostic significance of superb microvascular imaging (SMI) in rheumatoid arthritis (RA) patients in remission with normal C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR).

METHODS

The study enrolled 112 RA patients, and ultrasound (US) assessment was performed on 28 joints of each patient.

RESULTS

The SMI signal-positive rates for each joint were: metacarpophalangeal (MCP) joints: 20.5%, wrist joints: 43.8%, metatarsophalangeal (MTP) joints: 17.0%, and other foot joints: 25.0%. Investigation of the prognostic significance of the SMI signal in each joint revealed that only in the MTP joints was the total score of the SMI signal in the patients with relapse significantly higher than that in the patients with remission (P = 0.01). Comparison of the receiver operating characteristics curves for predicting relapse showed that the area under the curve (AUC) of the MTP joints was the highest (AUC = 0.66) of the investigated joints. The optimal threshold for the total MTP SMI score was 1 (accuracy = 83.3%). Positive/negative data of the SMI signal in the MTP joints were not significantly associated with the values of conventional disease activity markers.

CONCLUSION

In RA patients in remission with normal CRP and ESR levels, the percentage of positive SMI signal was highest in the wrist joints. However, the accuracy of the SMI signal for predicting relapse was greatest for the MTP joints, suggesting that US assessment of the MTP joints by SMI is useful for predicting relapse in these patients.

Biomarkers for treatment change and radiographic progression in patients with rheumatoid arthritis in remission: a 5 year follow-up study

OBJECTIVE

To identify biomarkers of treatment change and radiographic progression in patients with RA under remission.

PATIENTS AND METHODS

RA patients in remission (DAS28-ESR <2.6) were selected and followed up for 5 years. An MRI of the dominant hand and an US assessment of knees/hands and serum levels of inflammation/angiogenesis biomarkers were performed at baseline and at 12th month. Synovial biopsies were obtained in patients with Power Doppler signal. Conventional radiographies of hands/feet were taken at baseline and after 5 years. Radiographic progression was defined as the change in the modified Sharp van der Heijde Score at 5 years >10.47 (small detectable change).

RESULTS

Sixty patients were included, 81.6% were ACPA+ and 45% were taking biological DMARDs. At baseline, 66.6% had Power Doppler signal. After 5 years, 73.3% of patients remained in remission. Change of therapy was performed in 20 patients (33.3%) and was associated with BMI [odds ratio (OR) 1.3, 95% CI: 1, 1.7], lack of biological DMARD therapy (OR 24.7, 95% CI: 2.3, 257.2), first-year progression of MRI erosions (OR 1.2, 95% CI: 1, 1.3) and calprotectin serum levels (OR 2.8, 95% CI: 1, 8.2). Radiographic progression occurred in six (10%) patients. These patients had higher first-year progression of MRI erosions (P =  0.03) and bone oedema (P = 0.04). Among 23 patients undergoing synovial biopsy, mast cell density was independently associated with clinical flares.

CONCLUSIONS

One-third of RA patients lost clinical remission and changed therapy throughout the 5 years of follow-up, which was independently associated with BMI, lack of biological DMARDs therapy and first-year progression of MRI erosion score and calprotectin serum levels. Significant radiographic progression was uncommon.

Predicting Imaging Remission in Rheumatoid Arthritis: a Case-control Ultrasound Study

BACKGROUND

To elucidate the achievement rates of imaging remission and to examine the characteristics associated with imaging remission status among patients with rheumatoid arthritis (RA) who have attained clinical remission.

METHODS

Ninety-seven patients with RA patients who had attained clinical remission, defined by DAS28-ESR < 2.6 were enrolled. Power Doppler ultrasonography (PDUS) was performed on 16 joints and 2 tendons, including the first to third metacarpophalangeal, second and third proximal interphalangeal, radiocarpal (RC), second and third metatarsophalangeal joints, and extensor carpi ulnaris tendons. They were graded based on a dichotomous assessment. The clinical and laboratory data of patients who had attained imaging remission were compared to those of patients who had attained only clinical remission.

RESULTS

The imaging remission rate was 51.5% in patients who had attained clinical remission. Forty-seven patients (48.5%) were PDUS positive. Power Doppler was detected most frequently in the right RC joint (n = 40). PDUS positive patients had higher evaluator global assessment (EGA) scores (P < 0.001) than PDUS negative patients. PDUS positive patients also had higher clinical disease activity index and simplified clinical disease activity index scores than PDUS negative patients. Patients who had attained imaging remission had lower pain scores and used nonsteroidal anti-inflammatory drugs less frequently. Patients who had attained imaging remission had higher rheumatoid factor (RF) and anti-cyclic citrullinated peptide levels. A low EGA score was found to be a predictor of imaging remission achievement among patients who had attained clinical remission.

CONCLUSION

Only 51.5% of the patients with RA who had attained clinical remission were also in imaging remission. Patients who had attained imaging remission had lower EGA scores and higher RF levels than patients who had attained only clinical remission.

Contributing factors of clinical outcomes at 1 year post-diagnosis in early rheumatoid arthritis patients with tightly controlled disease activity in clinical practice: a retrospective study

OBJECTIVES

To determine whether specific parameters contribute to clinical outcomes at 1 year post-diagnosis in early rheumatoid arthritis (RA) patients under the 'treat-to-target' strategy in clinical practice.

METHODS

We retrospectively analyzed 125 RA patients selected according to the following criteria; the patients' symptom duration was ≤6 months, and none had experience with DMARDs. We evaluated the patients' clinical disease activity at baseline and 1 year of treatment and the musculoskeletal ultrasound (MSUS)-detected synovitis activity at baseline. We performed an analysis to identify parameters that contribute to SDAI remission and the use of biologic/targeted synthetic (b/ts) DMARDs at 1 year post-diagnosis.

RESULTS

Forty-seven patients received b/tsDMARDs therapy, and 58 patients achieved SDAI remission at 1 year post-diagnosis. Rheumatoid factor positivity, low patient's/evaluator's global assessment at baseline, and methotrexate use at 1 year post-diagnosis were associated with SDAI remission. The baseline clinical disease activity and MSUS scores were not associated with SDAI remission. Anti-cyclic citrullinated peptide antibody positivity/high titer and high swollen joint counts or the presence of severe synovial hypertrophy at baseline were associated with the use of b/tsDMARDs therapy.

CONCLUSION

The value of the expected poor-prognosis factors may be diminished by intensive therapy within the 'windows of opportunity'.

Treat-to-target strategies aiming at additional ultrasound remission is associated with better control of disease activity and less flare in rheumatoid arthritis

INTRODUCTION

Treat-to-target (T2T) strategy has greatly improved the prognosis of rheumatoid arthritis (RA). However, the additional benefit of targeting ultrasound (US) remission in addition to clinical remission has been debated.

METHODS

RA patients in clinical remission or low disease activity were enrolled. They were assorted into two groups according to the principle of T2T strategy adopted. In clinical group, treatment decision was made with the aim of maintaining DAS28(ESR) ≤ 3.2 only, while in clinical US group, the aim was to attain total power Doppler (PD) US score = 0 in addition to DAS28(ESR) ≤ 3.2. The time-averaged DAS28, flare, and changes of treatment strategy were compared.

RESULTS

One hundred ninety-four patients completed 1-year follow-up, with 100 in clinical US and 94 in clinical group. Compared to clinical group, time-averaged DAS28 in clinical US group was significantly lower (1.89 ± 0.51 vs. 2.33 ± 0.71, P < 0.01) with less flare (20.0% vs. 36.2%, P < 0.05). Furthermore, at the end of 1 year, significantly more patients successfully achieved step-down therapy (66.0% vs. 44.7%, P < 0.01) and dramatically fewer patients with step-up therapy in the clinical US group (13.0% vs. 25.5%, P < 0.05) compared to clinical group. In clinical US group, baseline DAS28(ESR) > 2.29, presence of subclinical synovitis, and step-down strategy were independent risk factors for relapse after clinical remission or low disease activity was achieved.

CONCLUSIONS

An US-driven T2T in addition to current clinical remission strategy is associated with better control of the disease activity, reduction of relapse, as well as long-term step-down therapy. Step-down strategy should be carefully applied to the patients with baseline DAS28(ESR) over 2.29 and presence of subclinical synovitis even after they have achieved clinical remission or low disease activity. Key Points • Targeting ultrasound remission in addition to current T2T strategy is associated with a better control of RA. • Step-down strategy should be cautiously considered in those with DAS28(ESR) > 2.29 and baseline subclinical synovitis after they have achieved clinical remission or low disease activity.

Subclinical Treatment Targets in Rheumatology: Lessons from Randomized Clinical Trials in Rheumatoid Arthritis

In treat-to-target strategies, choosing the correct target is fundamental to success. The target should be associated with future good outcomes for the patient. Most rheumatic diseases are characterized by inflammation, affecting different tissues depending on the condition. Low-grade, subclinical inflammation is by definition not apparent on clinical examination, but may have significant long-term consequences for the individual. It has thus been debated whether targeting subclinical inflammation would improve long-term outcomes in rheumatoid arthritis. The authors use rheumatoid arthritis as an example to describe and discuss the status of subclinical targets in treat-to-target strategies within rheumatology.

Update on the Pathomechanism, Diagnosis, and Treatment Options for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that involves multiple joints bilaterally. It is characterized by an inflammation of the tendon (tenosynovitis) resulting in both cartilage destruction and bone erosion. While until the 1990s RA frequently resulted in disability, inability to work, and increased mortality, newer treatment options have made RA a manageable disease. Here, great progress has been made in the development of disease-modifying anti-rheumatic drugs (DMARDs) which target inflammation and thereby prevent further joint damage. The available DMARDs are subdivided into (1) conventional synthetic DMARDs (methotrexate, hydrochloroquine, and sulfadiazine), (2) targeted synthetic DMARDs (pan-JAK- and JAK1/2-inhibitors), and (3) biologic DMARDs (tumor necrosis factor (TNF)-α inhibitors, TNF-receptor (R) inhibitors, IL-6 inhibitors, IL-6R inhibitors, B cell depleting antibodies, and inhibitors of co-stimulatory molecules). While DMARDs have repeatedly demonstrated the potential to greatly improve disease symptoms and prevent disease progression in RA patients, they are associated with considerable side-effects and high financial costs. This review summarizes our current understanding of the underlying pathomechanism, diagnosis of RA, as well as the mode of action, clinical benefits, and side-effects of the currently available DMARDs.

Predominant ultrasonographic extracapsular changes in symptomatic psoriatic dactylitis: results from a multicenter cross-sectional study comparing symptomatic and asymptomatic hand dactylitis

OBJECTIVE

Despite diffuse digital swelling, dactylitis may sometimes be asymptomatic. The objective of this study was to compare the clinical and ultrasonographic features of symptomatic with asymptomatic psoriatic arthritis (PsA) dactylitis.

METHODS

One hundred and twenty-five hand dactylitis were evaluated in a multicenter cross-sectional study for the presence of pain, subjective functional limitation, and tenderness (4-points scale) with the calculation of a Leeds Dactylitis Index (LDI) score. Fingers were subsequently investigated using high-frequency ultrasound (US) both in gray-scale (GS) and power Doppler (PD), for the presence and grading of flexor tenosynovitis, soft tissue edema, subcutaneous PD signal (PDUS), extensor tendon involvement, and joints synovitis. Clinical and US characteristics of symptomatic dactylitic fingers were compared with the asymptomatic dactylitic ones.

RESULTS

Symptomatic fingers (n = 80) had a significantly lower dactylitis duration compared to asymptomatic fingers (n = 36) (p < 0.001). Values of LDI, patient VAS-pain, and VAS-functional score were significantly higher in fingers with symptomatic dactylitis (p < 0.001 and p = 0.010, respectively). Symptomatic dactylitis had a higher prevalence of flexor tenosynovitis of grade > 2, soft tissue edema and subcutaneous PDUS signal (p < 0.001). Asymptomatic dactylitis showed a greater prevalence of joint synovitis (both in GS and in PD) than symptomatic dactylitis (p < 0.001).

CONCLUSIONS

Digital tenderness and pain are linked to US tenosynovitis of grade > 2 and extra synovial abnormalities and conversely asymptomatic dactylitis is associated with joint-based synovitis.Key Points• Digital tenderness and local pain in psoriatic arthritis dactylitis are strongly associated with flexor tenosynovitis of grade> 2, soft tissue edema, and subcutaneous PD signal.• In psoriatic arthritis, asymptomatic dactylitis showed a greater prevalence of joint synovitis than symptomatic dactylitis.• In psoriatic arthritis, ultrasound inflammatory abnormalities are present in about 70% of cold dactylitis which is linked for disease chronicity.• In psoriatic arthritis, the flexor tendon and adjacent soft tissues play a significant role in symptomatic dactylitis.

MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value

Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.

Ultrasound detected changes in joint cartilage thickness in juvenile idiopathic arthritis

AIM

The purpose of this study was to investigate the changes in joint cartilage thickness in different subtypes of juvenile idiopathic arthritis (JIA) using ultrasound, comparing them with healthy children and to evaluate the relationship with disease duration and inflammatory markers.

METHODS

We conducted a cross-sectional study comprising of 27 cases of JIA and 54 age- and sex-matched healthy children. Bilateral wrist, knee and ankle joint cartilage thicknesses were measured by ultrasound as per European League Against Rheumatism standard guidelines and compared them between JIA subtypes as well as between cases and control.

RESULTS

Descriptive analysis of the whole cohort revealed the mean age of the study population was 8.3 ± 3.2 years with mean cartilage thicknesses at the wrist, knee and ankle being 1.40 ± 0.89 mm, 1.57 ± 0.78 mm and 1.41 ± 0.85 mm, respectively. The median cartilage thicknesses of wrist, knee and ankle joints of JIA cases (n = 27) and healthy controls (n = 54) were 1.01, 1.35, 1.05 and 1.95, 2.00, 1.95, respectively. The joint cartilage thickness was significantly reduced in JIA in comparison to the healthy cohort (P < 0.01). Diseased boys suffered greater cartilage damage in knee joints compared to girls; the polyarticular variety of cases had thinner knee cartilage in comparison to the oligoarticular subtype. Further, it was found that joint cartilage destruction is independent of inflammatory markers and disease duration.

CONCLUSION

Significant cartilage thinning in addition was found in JIA children, particularly in the polyarticular subtype, and more in boys than girls, which is independent of disease duration and inflammatory markers, using ultrasound as a primary investigative tool.

MRI of synovitis and joint fluid

Synovitis and joint effusion are common manifestations of rheumatic disease and play an important role in the disease pathophysiology. Earlier detection and accurate assessment of synovial pathology, therefore, can facilitate appropriate clinical management and hence improve prognosis. Magnetic resonance imaging (MRI) allows unparalleled assessment of all joint structures and associated pathology. It has emerged as a powerful tool, which enables not only detection of synovitis and effusion, but also allows quantification, detailed characterization, and noninvasive monitoring of synovial processes. The purpose of this article is to summarize the pathophysiology of synovitis and to review the role of qualitative, semiquantitative, and quantitative MRI in the assessment of synovitis and joint fluid. We also discuss the utility of MRI as an outcome measure to assess treatment response, particularly with respect to osteoarthritis and rheumatoid arthritis. Emerging applications such as hybrid positron emission tomography / MRI and molecular imaging are also briefly discussed. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019.

Clinical, Patient-Reported, and Ultrasound Outcomes from an Open-Label, 12-week Observational Study of Certolizumab Pegol in Spanish Patients with Rheumatoid Arthritis with or without Prior Anti-TNF Exposure

OBJECTIVES

To assess the effectiveness and safety of certolizumab pegol (CZP) in Spanish patients with RA.

MATERIALS AND METHODS

SONAR (NCT01526434), a 12-week, open-label, prospective, observational, multicenter study. Patients with active RA for ≥3 months, according to ACR criteria, were treated with CZP (400mg at Weeks 0, 2 and 4, then 200mg every 2 weeks). The primary effectiveness endpoint was change from baseline (CFB) in Health Assessment Questionnaire-Disability Index (HAQ-DI) at Week 12. Other assessments included DAS28(ESR), patient's assessment of arthritis pain (PtAAP-VAS) and Short Form 36-item Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS). Joint inflammation was investigated using Power Doppler (PD) ultrasound (US), to detect effusion, synovial hypertrophy and synovial PD signal. PDUS outcomes assessed CFB to Week 12 in synovial hypertrophy, effusion and PD signal indices.

RESULTS

A total of 77/80 enrolled patients received ≥1 dose of CZP. The 12-week mean reduction from baseline (SD) was -0.6 (0.6) for HAQ-DI and -2.2 (1.5) for DAS28(ESR). PtAAP-VAS was reduced from baseline (mean [SD]: -36.8 [26.8]) and improvements in SF-36 PCS and SF-36 MCS were reported. Synovial hypertrophy, effusion and PD signal indices were reduced from baseline to Week 12. One death was reported during the study.

CONCLUSIONS

Spanish patients with RA demonstrated improvements in clinical, PDUS and patient-reported outcomes over 12 weeks of CZP treatment. No new safety signals were identified, and the safety profile was in line with previous CZP studies. These results support previous clinical trial findings investigating CZP treatment for active RA.

Ultrasound and its clinical use in rheumatoid arthritis: where do we stand?

High-resolution musculoskeletal ultrasound (MSUS) has been increasingly employed in daily rheumatological practice and in clinical research. In rheumatoid arthritis (RA), MSUS can be now considered a complement to physical examination. This method evaluates synovitis through gray-scale and power Doppler and it is also able to identify bone erosions. The utilization of MSUS as a marker of RA activity has received attention in recent literature. Current data account for good correlation of MSUS with classical measures of clinical activity; in some instances, MSUS appears to perform even better. Diagnosis of subclinical synovitis by MSUS might help the physician in RA management. With some variation, interobserver MSUS agreement seems excellent for erosion and good for synovitis. However, lack of MSUS score standardization is still an unmet need. In this review, we describe several MSUS scores, as well as their correlation with clinical RA activity and response to therapy. Finally, we look at the relationship of MSUS with synovial tissue inflammation and discuss future perspectives for a better interpretation and integration of this imaging method into clinical practice.

What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

BACKGROUND

Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US).

OBJECTIVE

To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015.

REVIEW METHODS

A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken.

MATHEMATICAL MODEL

A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated.

RESULTS

Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used.

LIMITATIONS

Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed.

CONCLUSION

Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015017216.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Can Ultrasound Be Used to Predict Loss of Remission in Patients with RA in a Real-life Setting? A Multicenter Cohort Study

OBJECTIVE

Several studies have suggested that patients with rheumatoid arthritis (RA) presenting with ultrasound (US) synovitis despite clinical remission have more subsequent flares than those who show both clinical and sonographic remission. The objective of our study was to investigate whether these results could be translated to a real-life setting.

METHODS

We compared the time from the first US performed in clinical remission to loss of remission (defined by a DAS28 > 2.6 or the need for stepping up treatment with disease-modifying antirheumatic drugs) within the Swiss Clinical Quality Management cohort of patients with RA, and we adjusted for relevant confounders. Analyses were repeated for different definitions of US-detected synovitis (US+) using greyscale, Doppler, and combined modes based on previously validated scores, and they were adjusted for relevant confounders.

RESULTS

There were 318 RA patients with 378 remission phases included. Loss of clinical remission was observed in 60% of remission phases. Residual US synovitis was associated with a shorter duration of clinical remission (median 2-5 mos) and a moderately increased hazard ratio (HR) for loss of remission (HR 1.2-1.5), with the highest HR for the combined US score. The association between US+ and loss of remission was strongest when the US measurement had taken place early in remission (shorter median duration of 6-20 mos) and when followup time was limited to the first 3 or 6 months (most HR between 2-4).

CONCLUSION

US-detected synovitis, particularly when US is performed early in clinical remission, has a moderate predictive power for loss of remission in a real-life setting.

Patients with juvenile idiopathic arthritis in clinical remission with positive power Doppler signal in joint ultrasonography have an increased rate of clinical flare: a prospective study

BACKGROUND

Ultrasonography (US) studies carried out on joints of juvenile idiopathic arthritis (JIA) patients in clinical remission demonstrate the presence of subclinical synovitis. The significance of subclinical synovitis and the positive power Doppler (PD) signal on US in JIA in clinical remission is not well understood. The objectives of this study were to assess whether the changes detected by US in patients with JIA in clinical remission can predict disease flare and to evaluate factors associated with flare and joint damage over 30 months of follow-up.

METHODS

A prospective study was performed with clinical and ultrasound evaluation in 34 joints of JIA patients in clinical remission. Clinical evaluation including physical exam, functional capacity and inflammatory markers was performed at baseline and every six months thereafter, for a total period of 30 months. US evaluation included presence of synovitis, PD signal and erosion at baseline and every 12 months thereafter. Subclinical synovitis was defined when there was synovitis with or without positive PD signal in US joints of patients in clinical remission. Flare was defined as any joint presenting clinical arthritis requiring therapy modification.

RESULTS

We evaluated a total of 35 patients, 28 (80%) girls, 14 (40%) persistent oligoarticular subtype, 12 (34.3%) oligoarticular extended and 9 (25.7%) polyarticular and 26 (74.3%) in remission on medication. Twenty (57.1%) patients flared. The risk of flare was five times higher in patients with positive PD signal and 14 times higher in patients in remission on medication. Regarding the assessment of joints after 6 months and 12 months of US evaluation, 70/3162 (2.2%) joints and 80/2108 (3.8%) joints flared, respectively. Joints with subclinical synovitis with positive PD signal flared more after 6 and 12 months. Twenty five of 2108 (1.2%) joints showed erosion over time. Joints with subclinical synovitis with or without positive PD signal showed more erosion.

CONCLUSIONS

Patients in remission on medication with subclinical synovitis with positive PD signal on US have a higher risk of flare, therefore they should be monitored closely during treatment. In the same way, joints with subclinical synovitis with or without positive PD signal should be monitored due to the risk of flare and joint damage.

No clear association between ultrasound remission and health status in rheumatoid arthritis patients in clinical remission

Objectives

Although RA patients achieve clinical remission, risk of flare still exists. Given the association between US synovitis and increased risk of flare, it is of clinical interest whether these patients report a different health status. Therefore, our aim was to evaluate the frequency of US remission in RA patients in clinical remission and to compare the health status of RA patients in clinical remission with those who were also in US remission.

Methods

In a prospective study, we included 89 RA patients (aged >17 years) treated with a synthetic DMARD and a TNF inhibitor who were in remission (DAS in 44 joints ⩽2.4 and swollen joint count ⩽1). Demographic characteristics, swollen and tender joints, laboratory variables, US (MCP2-5, PIP2-5, wrists and MTP2-5) and patient-reported outcomes (general health, functional ability, fatigue, depression and anxiety, pain and morning stiffness) were recorded at two consecutive visits (3 months apart). US remission was defined as grey scale grade ⩽1 and power Doppler = 0.

Results

At visit 1, 39% of patients were in US remission. At visit 2, 32% of patients were in US remission. At visit 1, functional ability (HAQ) was scored lower by patients in US remission (P = 0.029). At visit 2, HAQ scores were similar (P = 0.928). At visit 2, Hospital Anxiety and Depression Scale anxiety score and visual analog scale pain were significantly higher in patients in US remission. Similar levels were found for the other patient-reported outcomes.

Conclusion

One-third of RA patients in clinical remission were in US remission. In our study population, we could not find a clear association between health status of RA patients and being in US remission.

Perceptions of Doppler ultrasound for rheumatoid arthritis disease activity assessment and education

AIM

The aim of this qualitative study was to report the findings of the Defining rheumatoid arthritis progression using Doppler Ultrasound in Clinical practice (DEDUCE) Medical Practice Activity, which was developed to facilitate the utilization of Doppler ultrasound (DUS) by Australian rheumatologists in the treatment of patients with rheumatoid arthritis (RA).

METHOD

Twenty-one rheumatologists recruited a total of 80 patients with RA in Disease Activity Score of 28 joints (DAS28) remission for DUS assessment and completed a pre- and post-activity questionnaire assessing their experience with DUS, as well as a 6-month follow-up questionnaire. Rheumatologists discussed DUS results with patients using visual aids. Patients completed a pre- and post-DUS assessment questionnaire. Data were summarized using descriptive statistics.

RESULTS

Following completion of the activity, 95% of rheumatologists (20/21) believed DUS was a useful assessment tool for patients with RA. The majority found the DUS results useful and more than half thought the DUS assessment fit well into their consultation. A majority of rheumatologists indicated they would use DUS imaging in patients with low disease activity and remission, and for disease activity assessment to inform in therapeutic decision-making. All patients who responded found the visual aids useful and most felt that discussing DUS results improved understanding of their disease and would help with medication adherence.

CONCLUSION

Incorporation of DUS imaging into routine clinical practice is feasible, encourages rheumatologists to utilize and expand their clinical application of DUS imaging in patients with RA, and may improve patient understanding of their disease and adherence to medication.

Synovial features of patients with rheumatoid arthritis and psoriatic arthritis in clinical and ultrasound remission differ under anti-TNF therapy: a clue to interpret different chances of relapse after clinical remission?

Objective

To define the synovial characteristics of patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) in clinical and ultrasound remission achieved by combination therapy with methotrexate (MTX) and tumour necrosis factor (TNF) blockers.

Methods

Patients with RA in remission (n=25) (disease activity score (DAS)<1.6 for at least 6 months), patients with RA in low disease activity (LDA) (n=10) (1.6<DAS<2.4 for at least 6 months) and patients with PsA in remission (n=18) (DAS<1.6 and Psoriasis Area Severity Index (PASI)=0 for at least 6 months) achieved by MTX+anti-TNF (adalimumab 40 mg or etanercept 50 mg) with power Doppler (PDUS)-negative synovial hypertrophy underwent synovial tissue biopsy. Patients with RA with high/moderate disease naïve to treatment (n=50) were included as a comparison group. Immunostaining for cluster designation (CD)68, CD21, CD20, CD3, CD31 and collagen was performed.

Results

PDUS-negative patients with RA in remission showed lower histological scores for synovial CD68⁺, CD20⁺, CD3⁺ cells and CD31⁺ vessels and collagen deposition (p<0.05 for both lining and sublining) compared with PDUS-positive patients with RA with high/moderate disease. In addition, there was no significant difference in terms of lining and sublining CD68⁺, CD20⁺, CD3⁺, CD31⁺ cells and collagen comparing PDUS-negative patients with RA in remission and in LDA, respectively. On the contrary, PDUS-negative patients with PsA in remission showed higher histological scores for sublining CD68⁺ (p=0.02) and CD3⁺ cells (p=0.04) as well as CD31⁺ vessels (p<0.001) than PDUS-negative patients with RA in remission.

Conclusions

PDUS-negative patients with RA in remission have comparable synovial histological features than PDUS-negative patients with RA in LDA. However, patients with PsA in remission are characterised by a higher degree of residual synovial inflammation than patients with RA in remission, despite PDUS negativity under TNF inhibition.

Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis

OBJECTIVE

To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA).

METHODS

Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist.

RESULTS

A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies.

CONCLUSIONS

These recommendations will help clinicians use US and MRI in RA patients.

Predictive factors related to shoulder joint destruction in rheumatoid arthritis patients treated with biologics: A prospective study

OBJECTIVE

The aim of this study was to assess the risk factors for shoulder joint destruction in rheumatoid arthritis (RA) patients treated with biologics.

METHODS

Thirty shoulders of 29 patients with RA were assessed using 18F-fluorodeoxyglucose positron emission tomography (PET) and magnetic resonance imaging (MRI) before starting biologics and 6 months later. The mean age (range) was 54 (18-72) years, and the mean disease duration was 7 (0.8-30) years. The radiographic findings were assessed at baseline and 3 years later. The inflammation markers and RA disease activity were also assessed. These parameters were compared between the progression of joint destruction group and the no progression group.

RESULTS

The SUVmax on PET, the rate of synovitis, and the rate of rotator cuff tear on MRI before biologic treatment were significantly higher in the progression of joint destruction group. SUVmax and synovitis on MRI after 6 months were also significantly higher in the progression of joint destruction group. On logistic regression analysis, the SUV at baseline of the shoulder joint was the main risk factor for joint destruction.

CONCLUSION

The detection of synovitis by imaging was more important than disease activity and inflammation markers for assessing the progression of shoulder joint destruction.

Subclinical Synovitis Assessed by Ultrasound Predicts Flare and Progressive Bone Erosion in Rheumatoid Arthritis Patients with Clinical Remission: A Systematic Review and Metaanalysis

OBJECTIVE

Subclinical synovitis can be detected by ultrasound in patients with rheumatoid arthritis (RA) who are in clinical remission. We aimed to confirm its predictive value for flare and progressive bone erosion.

METHODS

A systematic literature search was performed in Pubmed, Web of Science, Embase, and Cochrane Library on September 7, 2014. Baseline clinical and ultrasonographic characteristics were collected. Methodological quality was assessed. Pooled OR were calculated using Mantel-Haenszel model. We explored the source of heterogeneity through subgroup analysis and completed a cumulative metaanalysis.

RESULTS

Thirteen articles were included (8 with flare, 4 with bone erosion, 1 with both flare and bone erosion). Metaanalysis revealed an association between power Doppler (PD) positivity and the risk of flare (OR 4.52, 95% CI 2.61-7.84, p < 0.00001, I² = 21%), the risk of progressive bone erosion on patient level (OR 12.80, 95% CI 1.29-126.81, p = 0.03, I² = 52%) and the risk of progressive bone erosion on joint level (OR 11.85, 95% CI 5.01-28.03, p < 0.00001, I² = 0%). Further subgroup analysis showed a higher risk of flare in patients with a study period < 1 year (OR 19.98 vs 3.41). No significant differences were observed in the subgroup analysis in duration of remission, disease duration, and medications. Moreover, cumulative metaanalysis indicated the validation and an increasing accuracy of PD positivity in predicting flare since 2012.

CONCLUSION

Ultrasound-detected subclinical synovitis can predict the risk of flare and progressive bone erosion in RA patients with clinical remission. Additionally, the flare of RA tends to occur within a followup of 1 year.

Changes in Ultrasonographic Vascularity Upon Initiation of Adalimumab Combination Therapy in Rheumatoid Arthritis Patients With an Inadequate Response to Methotrexate

Objective

To assess joint disease activity by ultrasound (US) in patients with rheumatoid arthritis (RA) initiating treatment with adalimumab (ADA) plus methotrexate (MTX).

Methods

Data for this post hoc analysis originated from the MUSICA trial (ClinicalTrials.gov identifier: NCT01185288), which evaluated the efficacy of initiating ADA (40 mg every other week) plus 7.5 or 20 mg/week MTX in 309 patients with RA with an inadequate response to MTX. Synovial vascularization over 24 weeks was assessed bilaterally at metacarpophalangeal joint 2 (MCP2), MCP3, MCP5, metatarsophalangeal joint 5, and the wrists by power Doppler US (PDUS). A semiquantitative 4‐grade scale was used. Disease activity was assessed using the Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP) and Simplified Disease Activity Index (SDAI). The correlation between continuous variables was assessed using Pearson's correlation coefficient.

Results

After 24 weeks of treatment with ADA plus MTX, rapid improvements in the mean synovial vascularity score were observed; the greatest improvements were in MCP2 (−0.5), MCP3 (−0.4), and the wrist (−0.4). At week 24, patients with the lowest DAS28‐CRP (<2.6) had the lowest mean 5‐joint and 3‐joint composite synovial vascularity scores. The 5‐joint and 3‐joint scores were strongly correlated (ρ > 0.9). Synovial vascularity scores correlated poorly with DAS28, swollen joint count in 66 joints (SJC66), SJC28, tender joint count in 68 joints (TJC68), TJC28, Clinical Disease Activity Index (CDAI), SDAI, physician's global assessment, patient's global assessment of pain, and disease duration (ρ < 0.2). Thirty‐two (70%) of 46 patients with a DAS28‐CRP of <2.6, and 11 (58%) of 19 patients with an SDAI indicating remission had at least 1 joint with a synovial vascularity score of ≥1.

Conclusion

PDUS detects changes in synovial vascularity in RA patients treated with ADA plus MTX, and residual synovial vascularity in patients in whom clinical disease control has been achieved.

Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission

The absence of specific guidance on how to use ultrasound (US) to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of US in clinical practice, potentially limiting its benefits for patient outcomes. In view of this, a group of musculoskeletal US experts formed a working group to consider how this unmet need could be satisfied and to produce guidance (additional to European League against Rheumatism (EULAR) imaging recommendations) to support clinicians in their daily clinical work. This paper describes this process and its outcome, namely five novel algorithms, which identify when US could be used. They are designed to aid diagnosis, to inform assessment of treatment response/disease monitoring and to evaluate stable disease state or remission in patients with suspected or established RA, by providing a pragmatic template for using US at certain time points of the RA management. A research agenda has also been defined for answering unmet clinical needs.

On-demand ultrasonography assessment in the most symptomatic joint supports the 8-joint score system for management of rheumatoid arthritis patients

OBJECTIVES

To investigate whether on-demand ultrasonography (US) assessment alongside a routine examination is useful in the management of rheumatoid arthritis (RA).

METHODS

US was performed in eight (bilateral MCP 2, 3, wrist and knee) joints as the routine in a cumulative total of 406 RA patients. The most symptomatic joint other than the routine joints was additionally scanned. Power Doppler (PD) and gray-scale images were scored semiquantitatively. Eight-joint scores were calculated as the sum of individual scores for the routine joints.

RESULTS

The most symptomatic joint was found among the routine joints in 209 patients (Group A) and in other joints in 148 (Group B). The PD scores of the most symptomatic joint correlated well with the 8-joint scores in Group A (r_s = 0.66), but not in Group B (r_s = 0.33). The sensitivity and specificity of assessment of the most symptomatic joint for routine assessment positivity were high (84.0% and 100%, respectively) in Group A, but low (50.0% and 61.8%, respectively) in Group B. Additional examination detected synovitis in 38% of Group B with negative results in the routine.

CONCLUSIONS

On-demand US assessment in the most symptomatic joint, combined with the routine assessment, is useful for detecting RA synovitis.

Tapering and discontinuation of TNF-α blockers without disease relapse using ultrasonography as a tool to identify patients with rheumatoid arthritis in clinical and histological remission

Background

In this study, we assessed whether clinical and ultrasonography (US)-based remission could be used to select patients with rheumatoid arthritis (RA) eligible to taper and discontinue anti-TNF-α therapy after achievement of remission, looking at disease relapse.

Methods

Forty-two patients with RA in sustained remission who were receiving anti-TNF-α treatment (Disease Activity Score <1.6 at three visits 3 months apart) underwent US evaluation of synovial hypertrophy (SH) and power Doppler (PD) signal presence. Five SH+/PD− patients with RA underwent US-guided knee synovial tissue biopsy to assess histological features of residual synovitis (CD68, CD3 and CD20 immunostaining) after sustained clinical remission was achieved. All patients were enrolled to taper first then discontinue anti-TNF-α. They were followed every 3 months afterwards, and the relapse rate was recorded.

Results

Selected SH+/PD− patients showed low-grade synovitis as demonstrated by the presence of CD68+ cells in the lining layer and few infiltrating CD3+ and CD20+ cells at the time sustained clinical remission was achieved. After anti-TNF-α tapering, 13 patients (30.9 %) relapsed and 29 (69.1 %) SH+/PD− patients maintained disease remission after 3 months and discontinued anti-TNF-α treatment. Among them, 26 patients (89.7 %) maintained disease remission status after 6 months of follow-up. All patients who relapsed were retreated with the previous biologic, following the last effective therapeutic regimen, again reaching a good European League Against Rheumatism response within 3 months.

Conclusions

US evaluation using PD signalling allows the identification of patients with RA in clinical and histological remission after tapering and discontinuing biologics.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-0927-z) contains supplementary material, which is available to authorized users.

Prediction of Large Joint Destruction in Patients With Rheumatoid Arthritis Using 18F-FDG PET/CT and Disease Activity Score

The assessments of joint damage in patients with rheumatoid arthritis (RA) are mainly restricted to small joints in the hands and feet. However, the development of arthritis in RA patients often involves the large joints, such as the shoulder, elbow, hip, knee, and ankle. Few studies have been reported regarding the degree of large joint destruction in RA patients. F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) visualizes the disease activity in large joints affected by RA. In this study, the associations between destruction of the large joints and the findings of FDG-PET/CT as well as laboratory parameters were investigated, and factors associated with large joint destruction after the administration of biological therapy were identified in RA patients. A total of 264 large joints in 23 RA patients (6 men and 17 women; mean age of 66.9 ± 7.9 years) were assessed in this study. FDG-PET/CT was performed at baseline and 6 months after the initiation of biological therapy. The extent of FDG uptake in large joints (shoulder, elbow, wrist, hip, knee, and ankle) was analyzed using the maximum standardized uptake value (SUVmax). Radiographs of the 12 large joints per patient obtained at baseline and after 2 years were assessed according to Larsen's method. A logistic regression analysis was performed to determine the factors most significantly contributing to the progression of joint destruction within 2 years. Radiographic progression of joint destruction was detected in 33 joints. The SUVmax at baseline and 6 months, and the disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) at 6, 12, and 24 months were significantly higher in the group with progressive joint destruction. The SUVmax at baseline and DAS28-ESR at 6 months were found to be factors associated with joint destruction at 2 years (P < 0.05). The FDG uptake in the joints with destruction was higher than that observed in the joints without destruction. The SUVmax at baseline and the DAS28-ESR at 6 months after the biological treatment were identified to be significant factors predicting destruction of the large joints at 2 years.

Consensus-based identification of factors related to false-positives in ultrasound scanning of synovitis and tenosynovitis

INTRODUCTION

We aimed to identify causes of false-positives in ultrasound scanning of synovial/tenosynovial/bursal inflammation and provide corresponding imaging examples.

METHODS

We first performed systematic literature review to identify previously reported causes of false-positives. We next determined causes of false-positives and corresponding example images for educational material through Delphi exercises and discussion by 15 experts who were an instructor and/or a lecturer in the 2013 advanced course for musculoskeletal ultrasound organized by Japan College of Rheumatology Committee for the Standardization of Musculoskeletal Ultrasonography.

RESULTS

Systematic literature review identified 11 articles relevant to sonographic false-positives of synovial/tenosynovial inflammation. Based on these studies, 21 candidate causes of false-positives were identified in the consensus meeting. Of these items, 11 achieved a predefined consensus (≥ 80%) in Delphi exercise and were classified as follows: (I) Gray-scale assessment [(A) non-specific synovial findings and (B) normal anatomical structures which can mimic synovial lesions due to either their low echogenicity or anisotropy]; (II) Doppler assessment [(A) Intra-articular normal vessels and (B) reverberation)]. Twenty-four corresponding examples with 49 still and 23 video images also achieved consensus.

CONCLUSIONS

Our study provides a set of representative images that can help sonographers to understand false-positives in ultrasound scanning of synovitis and tenosynovitis.

(18)F-FDG and (18)F-NaF PET/CT demonstrate coupling of inflammation and accelerated bone turnover in rheumatoid arthritis

OBJECTIVE

To compare the findings in rheumatoid arthritis (RA)-affected joints between (18)F-fluorodeoxyglucose (FDG) and (18)F-fluoride (NaF) positron emission tomography (PET)/computed tomography (CT).

METHODS

We enrolled twelve RA patients who started a new biologic agent (naïve 9 and switch 3). At entry, both hands were examined by (18)F-FDG PET/CT, (18)F-NaF PET/CT, and X-ray. Intensity of PET signals was determined by standardized uptake value max (SUVmax) in metacarpophalangeal (MCP), proximal interphalangeal (PIP), and ulnar, medial, and radial regions of the wrists. Hand X-rays were evaluated according to the Genant-modified Sharp score at baseline and 6 months.

RESULTS

Both (18)F-FDG and (18)F-NaF accumulated in RA-affected joints. The SUVmax of (18)F-FDG correlated with that of (18)F-NaF in individual joints (r = 0.65), though detail distribution was different between two tracers. (18)F-NaF and (18)F-FDG signals were mainly located in the bone and the surrounding soft tissues, respectively. The sum of SUVmax of (18)F-NaF correlated with disease activity score in 28 joint (DAS28), modified health assessment questionnaire (MHAQ), and radiographic progression. (18)F-FDG and (18)F-NaF signals were associated with the presence of erosions, particularly progressive ones.

CONCLUSION

Our data show that both (18)F-FDG and (18)F-NaF PET signals were associated with RA-affected joints, especially those with ongoing erosive changes.

Remission in rheumatoid arthritis: is it all the same?

Remission is the key treatment goal in rheumatoid arthritis and should provide the optimal state for patients. Clinical remission criteria are based on composite scores of disease activity and are widely used in clinical practice and trials. With the use of biologic therapies and treat to target strategies, rates of clinical remission have significantly improved. Despite achieving this target, many patients demonstrate structural and functional deterioration. This raises the question regarding the validity of clinical criteria, although they have evolved significantly over the years. Imaging modalities such as ultrasound have been described as more accurate methods of assessing the remission state compared with clinical assessment alone. Furthermore, immuno-pathological assessments are gaining significant interest as this would enable assessment of disease activity at the primary site of pathology. Further research is required to develop accurate biomarkers of remission. We aimed to review the evolution of remission criteria in rheumatoid arthritis to date and to evaluate novel concepts in and the future of defining remission.

Predicting joint destruction in rheumatoid arthritis with power Doppler, anti-citrullinated peptide antibody, and joint swelling

OBJECTIVE

To determine combined evaluation of musculoskeletal ultrasonography (MSUS) and power Doppler (PD) signals, anti-citrullinated peptide antibody (ACPA), and other clinical findings improve the prediction of joint destruction in rheumatoid arthritis (RA).

METHODS

We performed a retrospective study of 331 RA patients (female n = 280 and male n = 51, mean age: 57.9 ± 13.2 years) who underwent MSUS from 2002 to 2012. Correlations with progression of joint destructions in 1,308 2nd and 3rd metacarpophalangeal (MCP) joints and various factors including PD signals of the same joints, clinical findings, age, disease duration at the study entry, gender, observation period, radiographic bone scores according to modified Sharp-van der Heijde methods, ACPA, and rheumatoid factor (RF) were analyzed in patient- and joint-based fashions, using univariate and multivariate logistic regression analyses and generalized linear mixed model.

RESULTS

Patients' characteristics were as follows: mean disease duration: 5.7 ± 7.5 years, observation period: 4.6 ± 2.6 years, RF positivity: 79.9%, and ACPA positivity: 77.5%. PD-positive 2nd and 3rd joints showed higher rate of joint destruction, especially in ACPA-positive patients. Moreover, PD-positive joints in ACPA-positive patients showed joint destruction even in joints without swelling. Multivariate analysis determined PD, swollen joint (SJ), observation period, basal radiographic bone scores, and ACPA as independent risks for joint destruction.

CONCLUSION

PD, SJ, basal radiographic bone scores, and ACPA are independent predictors for the joint destruction of 2nd and 3rd MCPs in RA; thus, considering these factors would be useful in daily practice.

Sonographic measurements of low-echoic synovial area in the dorsal aspect of metatarsophalangeal joints in healthy subjects

INTRODUCTION

Assessment of synovitis in the metatarsophalangeal (MTP) joints with ultrasound has been shown to improve the accuracy of assessment of rheumatoid arthritis (RA). However, the presence of intraarticular low-echoic synovial area (LESA) in the MTP joints in healthy subjects complicates the sonographic assessment of these joints.

METHOD

Healthy subjects with no arthritic symptoms in their MTP joints were recruited. All subjects completed a questionnaire and underwent physical examination and sonographic assessment. LESAs in the dorsal aspect of all MTP joints were measured in the longitudinal view.

RESULTS

One thousand non-arthritic MTP joints in 100 healthy subjects (female 73, mean age 41.0 years old) were evaluated. Measurable LESAs were identified in all joints assessed. Mean length of LESA in each of the 1st-5th MTP joints was 17.8, 13.9, 11.9, 10.6, and 9.2 mm, respectively, whereas mean thickness was 2.4, 2.4, 1.8, 1.2, and 0.8 mm, respectively. Multivariate linear regression models identified the difference between 1st and 5th MTP joints as the most independently influential factor on the measurement of LESA.

CONCLUSIONS

Our data provide the normal reference values for the measurements of LESA in Japanese, which should be taken into consideration when the synovitis in MTP joints is evaluated with ultrasound.

Musculoskeletal ultrasound in rheumatology in Korea: targeted ultrasound initiative survey

AIM

In collaboration with the Targeted Ultrasound Initiative (TUI), to conduct the first study in Korea to investigate current practices in ultrasound use among Korean rheumatologists.

METHODS

We translated the TUI Global Survey into Korean and added questions to better understand the specific challenges facing rheumatologists in Korea. To target as many rheumatologists in Korea as possible, we created an on-line version of this survey, which was conducted from March to April 2013.

RESULTS

Rheumatologists are in charge of ultrasound in many Korean hospitals. Rheumatologists in hospitals and private clinics use ultrasound to examine between one and five patients daily; they use ultrasound for diagnosis more than monitoring and receive compensation of about US$30-50 per patient. There are marked differences in the rates of ultrasound usage between rheumatologists who work in private practice compared with tertiary hospitals. Korean rheumatologists not currently using ultrasound in their practice appear eager to do so.

CONCLUSION

This survey provides important insights into the current status of ultrasound in rheumatology in Korea and highlights several priorities; specifically, greater provision of formal training, standardization of reporting and accrual of greater experience among ultrasound users. If these needs are addressed, all rheumatology departments in Korea are likely to use ultrasound or have access to it in the future.

Does ultrasound-scored synovitis depend on the pharmacokinetics of subcutaneous anti-TNF agents in patients with rheumatoid arthritis?

OBJECTIVE

The aim of this study was to investigate the influence of the pharmacokinetics of s.c. anti-TNF agents on the grade of US-detected synovitis in RA patients.

METHODS

Fifty RA patients were prospectively recruited from the Biologic Therapy Unit of our hospital. Inclusion criteria were being in treatment with s.c. anti-TNF agents and having had neither changes in therapy nor local corticosteroid injections in the previous 3 months. Patients underwent clinical, laboratory [28-joint DAS (DAS28) and Simplified Disease Activity Index (SDAI)] and US assessment at two time points, i.e. at peak plasma drug concentration and at trough plasma drug concentration. US assessments were performed blindly to the anti-TNF agent, the administration time and the clinical and laboratory data. Twenty-eight joints were investigated for the presence and grade (0-3) of B-mode synovitis and synovial power Doppler signal. Global indices for B-mode synovitis (BSI) and Doppler synovitis (DSI) were calculated for 12 joints and for wrist-hand-ankle-foot joints. B-mode US remission was defined as a BSI <1 and Doppler US remission as a DSI <1.

RESULTS

There were no significant differences between the clinical, laboratory and B-mode and Doppler US parameters at peak time and trough time (P = 0.132-0.986). There were no significant differences between the proportion of patients with active disease and those in remission according to DAS28, SDAI, B-mode US and Doppler US at peak time and trough time assessments (P = 0.070-1).

CONCLUSION

Our results suggested that s.c. anti-TNF pharmacokinetics do not significantly influence US-scored synovitis in RA patients.

Contributions of ultrasound beyond clinical data in assessing inflammatory disease activity in rheumatoid arthritis: current insights and future prospects

Appropriate measures of disease activity need to be valid, reliable and sensitive to change for use in clinical studies while remaining at the same time feasible and practicable for utilization in daily clinical practice. Ultrasonography was shown to be a valid, sensitive and reliable imaging modality for the detection of synovitis in RA, however, it has so far failed to demonstrate superior sensitivity to change as compared with clinical examination. This review examines the current evidence for the use of established measures and/or US, either as an alternative or as a supplementary measure to clinical examination, as tools for monitoring synovitis in RA. It also includes a summary of results of recent studies evaluating clinical examination-based as well as clinical- and US-based multimodal disease activity indices. We review the rationale and limitations of incorporating US into composite disease activity indices and suggest a research roadmap for further studies in this field.

Determining a Magnetic Resonance Imaging Inflammatory Activity Acceptable State Without Subsequent Radiographic Progression in Rheumatoid Arthritis: Results from a Followup MRI Study of 254 Patients in Clinical Remission or Low Disease Activity

Objective.

To assess the predictive value of magnetic resonance imaging (MRI)-detected subclinical inflammation for subsequent radiographic progression in a longitudinal study of patients with rheumatoid arthritis (RA) in clinical remission or low disease activity (LDA), and to determine cutoffs for an MRI inflammatory activity acceptable state in RA in which radiographic progression rarely occurs.

Methods.

Patients with RA in clinical remission [28-joint Disease Activity Score-C-reactive protein (DAS28-CRP) < 2.6, n = 185] or LDA state (2.6 ≤ DAS28-CRP < 3.2, n = 69) with longitudinal MRI and radiographic data were included from 5 cohorts (4 international centers). MRI were assessed according to the Outcome Measures in Rheumatology (OMERACT) RA MRI scoring system (RAMRIS). Statistical analyses included an underlying conditional logistic regression model stratified per cohort, with radiographic progression as dependent variable.

Results.

A total of 254 patients were included in the multivariate analyses. At baseline, synovitis was observed in 95% and osteitis in 49% of patients. Radiographic progression was observed in 60 patients (24%). RAMRIS synovitis was the only independent predictive factor in multivariate analysis. ROC analysis identified a cutoff value for baseline RAMRIS synovitis score of 5 (maximum possible score 21). Rheumatoid factor (RF) status yielded a significant interaction with synovitis (p value = 0.044). RF-positive patients with a RAMRIS synovitis score of > 5 vs ≤ 5, had an OR of 4.4 (95% CI 1.72–11.4) for radiographic progression.

Conclusion.

High MRI synovitis score predicts radiographic progression in patients in clinical remission/LDA. A cutoff point for determining an MRI inflammatory activity acceptable state based on the RAMRIS synovitis score was established. Incorporating MRI in future remission criteria should be considered.