Clinical and ultrasound remission after 6 months of treat-to-target therapy in early rheumatoid arthritis: associations to future good radiographic and physical outcomes

Sundlisæter, Nina Paulshus; Aga, Anna‐Birgitte; Olsen, I.C.; Hammer, Hilde Berner; Uhlig, Till; Heijde, Desirée van der; Kvien, Tore K; Lillegraven, Siri; Haavardsholm, Espen A.

doi:10.1136/annrheumdis-2017-212830

Cited by 26 publications

(20 citation statements)

References 19 publications

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“…Previous studies have shown that joints with swelling and/or with ultrasound synovitis have a higher risk of radiographic damage, whereas no such association has been shown for joints being tender only 35–37. In addition, joints with no ultrasound detected synovitis have been shown not to develop radiographic progression 38 39. The association between swollen joints and ultrasound synovitis as well as subsequent radiographic damage is strongly supporting the inclusion of swollen joints in disease activity assessments.…”

Section: Discussionmentioning

confidence: 93%

Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis

et al. 2019

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ObjectivesJoint swelling and tenderness are considered a proxy for inflammation in patients with rheumatoid arthritis (RA). With ultrasound-detected inflammation as reference, our objectives were to explore on patient and joint level the associations between ultrasound synovitis and joint swelling, tenderness and patient-reported joint pain (PRJP).Methods209 patients with established RA were examined six times during 12 months with assessment of 32 joints in upper/lower extremities for joint swelling/tenderness and Grey scale (GS)/power Doppler (PD) synovitis. PRJP was assessed on a manikin. Correlations between different sum scores were at each examination calculated using Spearman’s rho (r), agreement at joint level was examined by Cohen’s kappa and logistic regression models were used to explore the associations between joint assessment and GS/PD scores.ResultsAt patient level, swollen joints were strongly correlated with GS/PD sum scores (r=0.64–0.88), while tender joints were primarily associated with PRJP (r=0.54–0.68). At joint level, GS/PD pathology had higher agreement with swelling (kappa 0.54–0.57) than tenderness (kappa 0.20–0.21) or PRJP (0.23–0.25). Higher percentages of joints were swollen according to increasing GS/PD scores, independently of joint tenderness. However, joints being tender, but not swollen, were not associated with GS/PD scores. Receiver operating curves showed swollen but not tender joints to be associated with GS/PD scores.ConclusionsSwollen joints were strongly associated with ultrasound detected synovitis at both patient and joint level, while this association was not found for tender joints. These results may question if tender joints reflect ongoing inflammation in established RA.

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Section: Discussionmentioning

confidence: 93%

Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis

et al. 2019

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“…One goal of this study was to increase the concordance between two equally applicable definitions of remission. While this may seem to be circular, it can also be seen as a strength, since both definitions have been confirmed to coincide with high predictive validity for the inhibition of bad outcome 11 39. This constitutes a main reason for targeting remission in the treatment of patients with RA.…”

Section: Discussionmentioning

confidence: 94%

Testing different thresholds for patient global assessment in defining remission for rheumatoid arthritis: are the current ACR/EULAR Boolean criteria optimal?

et al. 2020

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ObjectivesThis study aimed to evaluate different patient global assessment (PGA) cut-offs required in the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean remission definition for their utility in rheumatoid arthritis (RA).MethodsWe used data from six randomised controlled trials in early and established RA. We increased the threshold for the 0–10 score for PGA gradually from 1 to 3 in steps of 0.5 (Boolean1.5 to Boolean3.0) and omitted PGA completely (BooleanX) at 6 and 12 months. Agreement with the index-based (Simplified Disease Activity Index (SDAI)) remission definition was analysed using kappa, recursive partitioning (classification and regression tree (CART)) and receiver operating characteristics. The impact of achieving each definition on functional and radiographic outcomes after 1 year was explored.ResultsData from 1680 patients with early RA and 920 patients with established RA were included. The proportion of patients achieving Boolean remission increased with higher thresholds for PGA from 12.4% to 19.7% in early and 5.9% to 12.3% in established RA at 6 months. Best agreement with SDAI remission occurred at PGA cut-offs of 1.5 and 2.0, while agreement decreased with higher PGA (CART: optimal agreement at PGA≤1.6 cm; sensitivity of PGA≤1.5 95%). Changing PGA thresholds at 6 months did not affect radiographic progression at 12 months (mean ꙙsmTSS for Boolean, 1.5, 2.0, 2.5, 3.0, BooleanX: 0.35±5.4, 0.38±5.14, 0.41±5.1, 0.37±4.9, 0.34±4.9, 0.27±4.7). However, the proportion attaining HAQ≤0.5 was 90.2%, 87.9%, 85.2%, 81.1%, 80.7% and 73.1% for the respective Boolean definitions.ConclusionIncreasing the PGA cut-off to 1.5 cm would provide high consistency between Boolean with the index-based remission; the integer cut-off of 2.0 cm performed similarly.

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“…As such, this component of the disease should not be neglected, even if patients achieve remission and their general health status is good. An analysis of the ARCTIC data showed the highest odds ratio for no yearly radiographic progression in patients with remission observed on ultrasound [36]. By all means, this is not equivalent to a good combined outcome, which also includes physical function.…”

Section: Results -Selective Application Of Ultrasonography Testingmentioning

confidence: 94%

“…However, it should be emphasized once again that MSUS should not be considered an examination enabling an overall assessment of patients' health status. There are a number of other parameters that affect the health status of patients with RA -the authors themselves draw attention to this fact [36].…”

Section: Results -Selective Application Of Ultrasonography Testingmentioning

confidence: 99%

The changing role of ultrasonography examination in patients with rheumatoid arthritis in light of recent studies

Dura¹,

Żuchowski²,

Gorgolewski³

et al. 2020

Reumatologia

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For many years, ultrasonography (US) has been a widely accepted modality used for joint assessment in patients with rheumatoid arthritis (RA). Given the efficacy of present day therapies, there is scepticism whether it is required in the first place. The most recent clinical Targeting synovitis in Early Rheumatoid Arthritis (TaSER) and Clinical Tight Control Therapy (ARCTIC) trials' results appear to contradict it, yet this does not necessarily mean ultrasound has no place in modern rheumatology. The possibility of detecting inflammation at a subclinical level carries a tremendous predictive value, enabling identification of patients likely to experience an exacerbation in the coming months. Therefore, US should be a part of the decision-making process regarding treatment modification or introduction of any additional interventions, such as glucocorticosteroid injections. The results of the most recent clinical trials do not negate the usefulness of US, but merely suggest that it ought to be used in moderation.

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Clinical and ultrasound remission after 6 months of treat-to-target therapy in early rheumatoid arthritis: associations to future good radiographic and physical outcomes

Cited by 26 publications

References 19 publications

Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis

Swollen, but not tender joints, are independently associated with ultrasound synovitis: results from a longitudinal observational study of patients with established rheumatoid arthritis

Testing different thresholds for patient global assessment in defining remission for rheumatoid arthritis: are the current ACR/EULAR Boolean criteria optimal?

The changing role of ultrasonography examination in patients with rheumatoid arthritis in light of recent studies

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