Effect of Magnetic Resonance Imaging vs Conventional Treat-to-Target Strategies on Disease Activity Remission and Radiographic Progression in Rheumatoid Arthritis

Abstract

IMPORTANCE Whether using magnetic resonance imaging (MRI) to guide treatment in patients with rheumatoid arthritis (RA) improves disease activity and slows joint damage progression is unknown. OBJECTIVE To determine whether an MRI-guided treat-to-target strategy vs a conventional clinical treat-to-target strategy improves outcomes in patients with RA in clinical remission. DESIGN, SETTING, AND PARTICIPANTS Two-year, randomized, multicenter trial conducted at 9 hospitals in Denmark. Two hundred patients with RA in clinical remission (disease activity score in 28 joints-C-reactive protein [DAS28-CRP] <3.2 and no swollen joints) were enrolled between April 2012 and June 2015. The final follow-up visit was April 2017. INTERVENTIONS Patients were randomly allocated (1:1) to an MRI-guided vs a conventional treat-to-target strategy. In the MRI-guided group, the treatment goal was absence of MRI bone marrow edema combined with clinical remission, defined as DAS28-CRP of 3.2 or less and no swollen joints. In the conventional group, the treatment goal was clinical remission. MAIN OUTCOMES AND MEASURES Co-primary outcomes were proportions of patients achieving DAS28-CRP remission (DAS28-CRP <2.6) and with no radiographic progression (no increase in total van der Heijde-modified Sharp score) at 24 months. Significance testing for the primary outcome was based on 1-sided testing. Secondary outcomes were clinical and MRI measures of disease activity, physical function, and quality of life. RESULTS Of 200 patients randomized (133 women [67%]; mean [SD] age, 61.6 [10.5] years; median baseline DAS28-CRP, 1.9 [interquartile range, 1.7-2.2]; van der Heijde-modified Sharp score, 18.0 [interquartile range, 7.0-42.5]), 76 patients (76%) in the MRI-guided group and 95 (95%) in the conventional group completed the study. Of these, 64 (85%) vs 83 (88%), respectively, reached the primary clinical end point (risk difference, −4.8% [1-sided 95% CI, −13.6% to + ϱ; 1-sided P = .19]) and 49 (66%) vs 58 (62%), respectively, reached the primary radiographic end point (risk difference, 4.7% [1-sided 95% CI, −7.0% to + ϱ; 1-sided P = .25). Of 10 key secondary end points, 8 were null and 2 showed statistically significant benefit for the MRI treat-to-target group. Seventeen patients (17%) in the MRI-guided treat-to-target group and 6 patients (6%) in the conventional treat-to-target group experienced serious adverse events. CONCLUSIONS AND RELEVANCE Among patients with RA in clinical remission, an MRI-guided treat-to-target strategy compared with a conventional treat-to-target strategy did not result in improved disease activity remission rates or reduce radiographic progression. These findings do not support the use of an MRI-guided strategy for treating patients with RA.

Efficacy of pharmacological treatment in rheumatoid arthritis: a systematic literature research informing the 2019 update of the EULAR recommendations for management of rheumatoid arthritis

“…Further, studies on tapering and stopping treatment broaden the information base for rheumatologists and patients on the question of possible disease flares after tapering or cessation of drugs, once patients have reached the clinical target. Strategic studies on how to optimally treat patients to target,5 using clinical and imaging targets have also answered important research questions 6. Finally, a large number of trials compared the efficacy and safety of biosimilars (bs) DMARDs with those of their bio-originators (bo), including switching between boDMARD and respective bsDMARDs.…”

Comparable Clinical and Radiographic Outcomes among DAS28-ESR-based Remission Criteria and SDAI, CDAI, and ACR/EULAR Boolean definitions in patients with Established Rheumatoid Arthritis in Clinical Practice. Observational Study of 5 years of Follow-Up

“…Ideally, achieving US remission and the complete abrogation of subclinical activity should be the ultimate goal for our RA patients. However, recent data from TASER [17], ARTIC [29] and IMAGINE-RA [30] trials showed that speci cally targeting subclinical in ammation did not yield better clinical outcomes. This target could imply a risk of overtreating, with a higher use of biological therapy and more adverse events.…”

Prediction of radiographic progression during a treat-to-target strategy by the sequential application of MRI-proven bone marrow edema and power-Doppler grade ≥2 articular synovitis in rheumatoid arthritis: retrospective observational study

“…However, despite the utility of MRI-demonstrated BME and PD-revealed articular synovitis, the roles of MRI and US monitoring for patients with RA in clinical settings have been controversial. In the IMAGINE-RA study of MRI, the use of MRI for treatment guidance did not improve the rate of disease activity remission or that of radiographic progression compared to a conventional treat-to-target (T2T) strategy [20]. In the TaSER study and the ARCTIC study of ultrasound, compared to clinical evaluations, the use of US for monitoring a cohort of early and active RA patients did not result in a higher frequency of patients in remission [21,22].…”