Presence of significant synovitis in rheumatoid arthritis patients with disease‐modifying antirheumatic drug–induced clinical remission: Evidence from an imaging study may explain structural progression

Abstract

Objective. More timely and effective therapy for rheumatoid arthritis (RA) has contributed to increasing rates of clinical remission. However, progression of structural damage may still occur in patients who have satisfied remission criteria, which suggests that there is ongoing disease activity. This questions the validity of current methods of assessing remission in RA. The purpose of this study was to test the hypothesis that modern joint imaging improves the accuracy of remission measurement in RA.Methods. We studied 107 RA patients receiving disease-modifying antirheumatic drug therapy who were judged by their consultant rheumatologist to be in remission and 17 normal control subjects. Patients underwent clinical, laboratory, functional, and quality of life assessments. The Disease Activity Score 28-joint assessment and the American College of Rheumatology remission criteria, together with strict clinical definitions of remission, were applied. Imaging of the hands and wrists using standardized acquisition and scoring techniques with conventional 1.5T magnetic resonance imaging (MRI) and ultrasonography (US) were performed.Results. Irrespective of which clinical criteria were applied to determine remission, the majority of patients continued to have evidence of active inflammation, as shown by findings on the imaging assessments. Even in asymptomatic patients with clinically normal joints, MRI showed that 96% had synovitis and 46% had bone marrow edema, and US showed that 73% had gray-scale synovial hypertrophy and 43% had increased power Doppler signal. Only mild synovial thickening was seen in 3 of the control subjects (18%), but no bone marrow edema.

Frequency, predictors, and prognosis of sustained minimal disease activity in an observational psoriatic arthritis cohort

“…We also know that clinical examination does not identify all inflamed joints and that it is particularly insensitive to low levels of inflammation (subclinical disease) (18). Even in patients with rheumatoid arthritis who are in remission (as defined by Disease Activity Score), joint damage progression has been shown to occur and is related to subclinical inflammation seen on imaging (19). In the current study, a clinically damaged joint count was used rather than an assessment of joint damage on conventional radiography.…”

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.…”

Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound

“…GS and PD were scored separately on a semiquantitative (SQ) scale (range 0 -3; as used in RA studies [12]) for each enthesis imaged. The GS score was a composite score of tendon/aponeurosis thickening and hypoechogenicity (loss of fibrillar pattern), using the highest score for either parameter as the final GS score.…”