Ultrasound Helps Guide Arthritis Treatment

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Ultrasound Helps Guide Arthritis Treatm

Scottish researchers have discovered that integrating musculoskeletal ultrasound into disease activity evaluations significantly helped guide and inform treatment decision-making in early rheumatoid arthritis.

According to James Dale, MBChB, and colleagues from the University of Glasgow, in 29% of clinical assessments that included a musculoskeletal ultrasound, the imaging study supplied data that modified the decision of whether a change in disease-modifying anti-rheumatic drug (DMARD) therapy was accurate.

For example, among patients who met the disease's activity score in 28 joints (DAS28) for low disease activity, 25% of the musculoskeletal ultrasounds showed ongoing disease activity and resulted in DMARD escalation.

The researchers work has gone on to be published in Arthritis Care and Research.

"Treat to target," has become a popular treatment plan in rheumatoid arthritis, based on the notion that patients should be assessed frequently and treatment elevated until they reach a state of low disease activity (DAS28 below 3.2) or remission (DAS28 below 2.6).

However, multiple clinical scores such as the DAS and the DAS28 have disadvantages and limitations; including a lack of information about the feet and the observation that subclinical synovitis can persist even in low disease activity states.

"In essence, DAS/DAS28 have less than perfect sensitivity and specificity for the assessment of overall disease activity and may either under- or overestimate the true inflammatory disease burden," Dale and peers wrote.

To test the theory that musculoskeletal ultrasound could assist in the accuracy of disease evaluation, the researchers set forth a randomized study in which 111 patients with early or undifferentiated arthritis were registered between September 2009 and April 2012.

All participants received monthly DAS28 evaluations and 53 also had periodic sonographic evaluation of 14 joints of the hands, wrists, and feet.

Active disease that called for DMARD escalation was defined as the presence of a power Doppler signal in at least two joints, and treatment escalation was standardized beginning with methotrexate monotherapy and increasing to triple DMARD therapy and then adding etanercept (Enbrel).

Among the 53 patients in the ultrasound group, average disease duration was 5.1 months.

Mean DAS28 at baseline was 5, average swollen joint count was 5.8, tender joint count averaged 6.1, and erythrocyte sedimentation rate was 35.9 mm/hour.

During the course of the study, the ultrasound group had 753 clinical evaluations and 414 sonographic assessments.

In the 414 musculoskeletal ultrasounds, 59% detected power Doppler signals in at least one joint, 26% detected signals in two or more joints, and 9% showed signals in three or more joints.

There were 271 ultrasound assessments in patients who were noted as being in remission, yet in 24% of these, signals were detected in two or more joints, which led to DMARD escalation.

On the other hand, in 45 ultrasound evaluations where DAS28 scores were between 3.2 and 5.1, reflecting moderate disease activity, the imaging study revealed that no disease activity was present in 67%, so DMARD escalation was unnecessary.

In that subgroup of patients, the clinical disease activity reflected by the DAS28 score may have been the result of coexisting noninflammatory conditions such as osteoarthritis or fibromyalgia.

That discovery implied that patients who otherwise might have been considered for DMARD escalation, with its attendant risks, could be put into treatments more likely to be effective, according to the researchers.

An additional finding was that average power Doppler scores fell over time from 2.70 to 1.34 (P<0.001).

Dale and colleagues noted that incorporating musculoskeletal ultrasound into clinical practice "will require careful consideration of what is required for a reliable assessment and what is achievable during daily practice."

This will involve the development of an agreement about how many and which joints should be included in the evaluation, and determination of whether the treatment target should be low disease activity or remission.

"Taken together, these results suggest that systematic [musculoskeletal ultrasound] examination could become a useful adjunct to clinical examination in a carefully selected subset of patients," they stated.

This subset could also include patients who no longer have clinical manifestations of synovitis but may still have residual disease activity detectable on imaging.

Yet, the researchers cautioned that they do not have the required data to verify that the integration of ultrasound to clinical evaluation will actually have an impact on patient outcomes, and whether patients in clinical remission should be offered costly biologic therapy if residual synovitis is found.

Eventually the team concluded that a "robust cost-effectiveness analysis should be done that considers the costs of equipment, training, and clinician time, as well as potential savings in expensive treatments, before widespread adoption of ultrasound for this purpose can be recommended."

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