Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission

Abstract

The absence of specific guidance on how to use US to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of ultrasound (US) in clinical practice, potentially limiting its benefits for patient outcomes. In view of this, a group of musculoskeletal US experts formed a working group to consider how this unmet need could be satisfied and to produce guidance (additional to EULAR imaging recommendations) to support clinicians in their daily clinical work. This paper describes this process and its outcome, namely six novel algorithms, which identify when US could be used. They are designed to aid diagnosis, inform assessment of treatment response/disease monitoring and to evaluate stable disease state or remission in patients with suspected or established RA, by providing a pragmatic template for using US at certain time points of the RA management. A research agenda has also been defined for answering unmet clinical needs. D A ARD-2016-209646 revised clean version 3Recently, the European League Against Rheumatism (EULAR) has produced recommendations for using imaging in rheumatoid arthritis (RA) management to aid diagnosis, assessment of prognosis, assessment of treatment response/disease activity and to support remission surveillance. 1 How these recommendations should be applied, however, is open to interpretation.Among the different imaging techniques, ultrasound (US) has shown to be of particular help in the diagnostic work-up of RA, in guiding treatment decisions and in monitoring disease activity and remission. Despite the difference in the quality of the US machines 2-4 and the possible different level of experience of the operators, published data supports the value of using US in the management of patients with inflammatory arthritis. 1 5 This evidence has encouraged many rheumatologists to embrace US in their clinical practice. 6 The expansion of US in rheumatology has occurred alongside, and is complementary to, the acceptance of the treat-to-target model, in which disease activity and response to treatment must be closely monitored. 7 The prompt diagnosis of RA and early initiation of disease-modifying anti-rheumatic drugs (DMARDs) reduce inflammation, limit disease progression, control symptoms and minimise functional loss. [8][9][10] According to the American College of Rheumatology (ACR)/EULAR classification criteria, 11 a patient with synovitis can be classified as having RA if a certain number of joints with synovitis are detected or if bone erosions are present. However, clinical examination and conventional radiography (CR) are neither sensitive nor accurate enough to detect disease activity and structural damage in early disease. [12][13][14][15] In contrast, US is able to detect synovitis at presentation and differentiate between intra-joint synovial inflammation and other causes of symptoms/swelling, such as tenosynovitis, bursitis and other soft tissue lesions. [16][17][18][19][20] This is also reflect...

Defining refractory rheumatoid arthritis

“…Central to this is confirming persistent inflammation (synovitis and/or systemic), distinct from solely clinically relevant biomechanical and degenerative drivers, so that we do not only include a surrogate for longer disease duration and damage 24. Ultrasound imaging and presence of power Doppler is appropriate if/when clinical assessment is not clear 25. The presence or absence of ADA can provide further clarification such that refractory response can be stratified into the following groups (illustrated in figure 2 and also applied to categorisation of successive refractory drug outcomes):…”

Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management

“…The added value of US has been advocated at all levels of the disease stages4: from predicting diagnosis,1 to supporting the diagnostic and classification process,5 guiding treatment choices and response,6 predicting structural damage and flares,7 8 and influencing the concept and management of remission and treatment tapering 9 10. US has been shown to be superior to clinical assessment in detecting inflammation by assessing the presence of the most important elementary lesions in RA: synovial hypertrophy (SH), synovial effusion (SE) and Power Doppler activity (PD) 2.…”

Is it time to revisit the role of ultrasound in rheumatoid arthritis management?

“…However, as with the introduction of any new medical technology or test, we still lack knowledge on how to best use US in routine care 4. All this was well highlighted in the European League Against Rheumatism recommendations on the use of imaging in rheumatoid arthritis (RA) clinical practice, which demonstrated the gaps in the current knowledge base and highlighted the need for strategy trials 3…”