Disease remission state in patients treated with the combination of tumor necrosis factor blockade and methotrexate or with disease‐modifying antirheumatic drugs: A clinical and imaging comparative study

Abstract

Objective. For patients with rheumatoid arthritis (RA) in remission who are receiving disease-modifying antirheumatic drugs (DMARDs), radiographic progression correlates with imaging-detected synovitis as measured by power Doppler activity. In contrast, patients with disease in remission who are receiving the combination of tumor necrosis factor (TNF) blockade with methotrexate (MTX) (combination treatment) have reduced radiographic damage for the equivalent clinical state. We undertook this study to determine whether the difference in radiographic outcome is a result of more complete suppression of imaging-detected synovitis.Methods. One hundred patients with RA in remission (Disease Activity Score in 28 joints [DAS28] <2.6) for at least 6 months while receiving either combination treatment (n ‫؍‬ 50) or DMARDs (n ‫؍‬ 50) were matched for clinical variables. Ultrasound of metacarpophalangeal joints 1-5 and the wrist joints was performed. Remission according to imaging results was defined as a score of 0 for both grey scale synovitis and power Doppler activity.Results. In patients receiving combination treatment or DMARDs (median DAS28 1.65 versus 1.78, median disease duration 120 months versus 90 months, and median duration of remission 13 months versus 18 months), the proportion with remission according to imaging results was not significantly different (10% versus 16%, respectively). The combination treatment group had more grey scale synovitis (P < 0.001) but similar power Doppler activity (48% versus 60%, respectively; P ‫؍‬ 0.229) in any joint as compared with the DMARD group. Results were not affected by stratification for duration of disease or remission.Conclusion. In RA patients with disease in remission, imaging-detected synovitis persists, with power Doppler activity seen in >48% of the patients regardless of therapy. These results suggest that superior radiographic outcomes in patients treated with the combination of TNF blockade and MTX may not be due to complete suppression of imaging-detected synovitis.Disease remission is the major goal for patients with rheumatoid arthritis (RA) (1).

Clinical and Ultrasound‐Based Composite Disease Activity Indices in Rheumatoid Arthritis: Results From a Multicenter, Randomized Study

“…Several studies have investigated the use of ultrasound in detecting and evaluating subclinical disease (33)(34)(35)(36)(37). Sonography detected synovitis as a surrogate of subclinical disease activity in almost two-thirds of patients with early, untreated oligoarthritis, whereas one-third of patients could be reclassified as having polyarticular disease (33).…”

Changes in hand bone mineral density and the association with the level of disease activity in patients with rheumatoid arthritis: Bone mineral density measurements in a multicenter randomized clinical trial

“…It may also be that DAS Ͻ1.6 is insufficiently strict to identify true remission, with residual inflammation undetected by clinical evaluation. Magnetic resonance imaging in patients in clinical remission may show signs of synovitis (40,41), and in some, radiologic joint damage progression has been reported (42,43). Ongoing mBMD loss may be a signal of persistent disease activity, and mBMD measurement may help to identify patients at risk for radiographic progression who clinically appear to be in remission.…”

Management of Rheumatoid Arthritis: Consensus Recommendations From the Turkish League Against Rheumatism

“…[3,58,59,118] It has been reported in some power Doppler imaging studies that there is ongoing synovitis, even in patients under remission. [119] Moreover, it has also been suggested in several recent studies that it would not be appropriate to characterize biological agents as undeniably more clinically effective than synthetic DMARDs. [120] From this perspective, the use of two or three DMARDs in combination with GCs or the combination of a DMARD with an anti-TNF agent, both of which may be characterized as intensive treatment, is recommended in all patients in the active or therapeutic window period.…”