medwireNews: Study results contradict suggestions that the routine use of ultrasound to target imaging remission in early rheumatoid arthritis (RA) provides additional benefit over achieving clinical remission.
The study, presented in a poster session at the 2019 ACR/ARP Annual Meeting in Atlanta, Georgia, USA, found that the 116 patients who had no power-Doppler signal in any joint, as assessed by ultrasound, in addition to meeting conventional treatment targets of a DAS score below 1.6 and no swollen joints had a similar reduction in combined magnetic resonance imaging (MRI) inflammation score over 2 years as the 102 patients assigned to a conventional strategy alone.
The study used data from the randomized ARCTIC trial, the primary analysis of which did not show a beneficial effect of adding structured ultrasound assessment to a treat-to-target strategy, but did show a trend toward less radiographic progression in those assessed by ultrasound.
This was not supported in the current analysis, however. MRI inflammation scores fell in the first 3 months in patients in both the ultrasound arm and the conventional strategy arm, and continued to do so during the first year, by an average of 64.2 in the ultrasound arm and 59.4 in the conventional treatment arm, before reaching a plateau that was maintained through year 2.
Researcher Espen Haavardsholm (Diakonhjemmet Hospital, Oslo, Norway) pointed out that there was no significant difference in scores between the two groups at any timepoint.
There was also no significant difference in the percentage of patients who had MRI erosive progression in the ultrasound and conventional groups, with a mean change from baseline of 39% and 33%, respectively.
The researchers note that the change in mean MRI damage scores was driven by a high progression rate in a minority of patients, whereas there was little or no progression in the majority.
All the patients were treated using the same DMARD escalation program, starting with methotrexate, then combination treatment with methotrexate/sulfasalazine/hydroxychloroquine, and finally a biologic DMARD.
For those in the ultrasound arm, MRI of the dominant hand was performed at six timepoints and scored according to the OMERACT MRI Scoring System, with treatment stepped up if indicated. The image remission target overruled the DAS and swollen joint count criteria.
All the patients had an MRI at baseline and at least one follow-up visit, and a combined inflammation score was computed based on normalized summation of RAMRIS synovitis, tenosynovitis, and bone marrow edema scores, while MRI damage was scored based on the normalized summation of the erosion and joint space narrowing scores.
Haavardsholm told the press: “The main message is that people with RA should be diagnosed and started on treatment early, monitored closely, and treatment should be stepped up aggressively until the target of clinical remission is reached.
“The strategy has proven very successful. However, going beyond this by aiming to also achieve imaging remission increases treatment cost and effort, but does not significantly further improve the results.”
Speaking to medwireNews, Haavardsholm noted that although the findings suggest against the routine use of ultrasound to monitor disease activity, they have found its high sensitivity “very helpful” for guiding joint injection.
By Lucy Piper
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ACR/ARP 2019; Atlanta, Georgia, USA: 8–13 November