Subclinical synovitis measured by ultrasound in rheumatoid arthritis patients with clinical remission induced by synthetic and biological modifying disease drugs

Cruces, Marcos; Snih, Soham Al; Serra-Bonett, Natali; Rivas, Juan Carlos

doi:10.1016/j.reuma.2017.08.004

Cited by 9 publications

(11 citation statements)

References 18 publications

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“…Our findings of subclinical synovitis regardless of the clinical remission criteria applied and independent of the type of treatment are in line with other studies published over a period of more than 10 years [12][13][14]16]. However, in our study, only 7% of the patients were in strict ultrasound remission and this was only observed in bDMARD-treated patients.…”

Section: Discussionsupporting

confidence: 92%

“…Despite data showing that subclinical inflammation as detected by ultrasound and magnetic resonance imaging is present in a substantial proportion of patients with RA in clinical remission [6][7][8][9][10][11][12], it was decided not to include imaging remission into the updated EULAR T2T recommendations, leaving clinical remission as the therapeutic target [4]. However, data shows that subclinical synovitis detected by ultrasound seems to be independent of the applied clinical remission criteria and type of treatment (conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) or biological DMARD (bDMARD)) [12][13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

“…Ultrasound remission is therefore generally perceived as an ultrasound disease state without Doppler activity, but different studies put different emphasis on the presence of synovial hypertrophy by grey-scale (GS) ultrasound. Though subclinical synovitis in patients in remission has been assessed previously, none of the studies evaluated patients in longstanding remission obtained through a DAS28 T2T-steered strategy applied in routine care [6,7,[12][13][14][15][16].…”

Section: Introductionmentioning

confidence: 99%

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Using a DAS28-CRP-steered treat-to-target strategy does not eliminate subclinical inflammation as assessed by ultrasonography in rheumatoid arthritis patients in longstanding clinical remission

et al. 2021

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Background Subclinical synovitis by ultrasound is a frequent finding in rheumatoid arthritis (RA) patients in remission and has been shown to be related to erosive progression, risk of flare and unsuccessful drug tapering, but it has not been investigated how a DAS28 T2T-steered strategy in routine care affects the presence of subclinical synovitis in RA patients in remission. The aim of the current study was to investigate the presence of ultrasound-detected subclinical inflammation in RA patients in long-term remission receiving either biological or conventional disease-modifying anti-rheumatic drugs (bDMARD/csDMARD) and, finally, to investigate the presence of ultrasound remission using different ultrasound remission criteria. Methods Eighty-seven RA patients (42 patients receiving bDMARD and 45 csDMARD) received DAS28-CRP-steered treatment in routine care and had achieved DAS28-CRP-remission for > 1 year without radiographic progression. Twenty-four joints were scored 0–3 by ultrasound (elbows, wrists, knees, ankles, metacarpophalangeal and metatarsophalangeal joints 2–5) for grey-scale synovial hypertrophy (GS) and colour Doppler activity (CD) using the OMERACT scoring system. Ultrasound remission was defined as strict (GS score = 0 and CD score = 0), semi-strict (GS score < 1 and Doppler score = 0) and Doppler remission (Doppler score = 0). Results No differences between treatment groups were found for GS sum score and Doppler sum score (median (range) 6 (0–19) and 0 (0–12), respectively). A Doppler score > 0 in at least 1 joint was seen in 44%, a GS score > 1 in at least 1 joint in 93% and a GS score > 2 in at least 1 joint in 54% of patients. Strict ultrasound remission was only observed in bDMARD patients (7%; p = 0.01). Thirty-seven per cent were in semi-strict ultrasound remission and 56% in Doppler remission (no significant difference between groups) with similar results across the subgroups of patients who also fulfilled the ACR-EULAR Boolean-, CDAI- and SDAI-remission criteria. Conclusions Ultrasound frequently detected subclinical synovitis in RA patients in longstanding DAS28-remission obtained through a DAS28-CRP-steered strategy. This was independent of treatment and applied ultrasound remission criteria. Strict ultrasound remission was rare.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Using a DAS28-CRP-steered treat-to-target strategy does not eliminate subclinical inflammation as assessed by ultrasonography in rheumatoid arthritis patients in longstanding clinical remission

et al. 2021

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“…Strict ultrasound remission (ie no synovial hypertrophy and no Doppler activity in any joint) has been reported in 7–35% of patients in remission, whereas Doppler remission is more frequent and has been reported in 46–76% of patients. 19 , 29 , 31 , 32 This indicates that clinical treatment with or without a T2T approach is more likely to result in Doppler remission than a complete absence of imaging signs of synovial hypertrophy.…”

Section: Defining Imaging Remissionmentioning

confidence: 99%

Rheumatoid Arthritis Relapse and Remission – Advancing Our Predictive Capability Using Modern Imaging

Terslev¹,

Østergaard²

2021

JIR

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Clinical remission has become an achievable target for the majority of patients with rheumatoid arthritis, but subclinical inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) has been demonstrated to be frequent in patients in clinical remission. Subclinical synovitis has been shown to be linked to both subsequent structural damage progression and a risk of flare, demonstrating that subclinical synovitis represents incomplete suppression of inflammation and questions whether it is appropriate only to use clinical composite scores as treatment target in clinical practice. Maintaining a state of remission has proven important as sustained clinical remission impacts long-term outcome regarding joint damage progression, physical function and quality of life. Treating subclinical inflammation has been attempted and has led to more frequent strict clinical remission and better physical function, but also to more adverse events. Thus, an overall benefit of incorporating imaging goals in treat-to-target strategies has not been documented. However, in patients in clinical remission on biological disease-modifying anti-rheumatic drugs, both ultrasound and MRI may aid in the clinical decision regarding whether drug tapering or even discontinuation should be attempted.

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“…Imaging of joints and tendons is a feasible choice. In patients with DAS28-defined remission, ultrasound is able to detect grey scale synovial hypertrophy (SH) (10) and positive power Doppler (PD) synovitis and tenosynovitis both in joints included in the clinical evaluation of composite scores (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) and also in the excluded joints, such as the ankles (22,23) and feet (24)(25)(26)(27)(28)(29)(30)(31), regardless of treatment type (32). Convincing literature evidence shows that there is a quantitative positive relationship between remission and residual ultrasound activity.…”

Section: Introductionmentioning

confidence: 99%

Clinical and ultrasound ankle involvement in rheumatoid arthritis in remission

Enache¹,

Popescu²,

Codreanu³

et al. 2019

Ro J Rheumatol.

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Objective. We aimed to evaluate the prevalence and differences of clinical and ultrasound involvement of ankles in rheumatoid arthritis (RA) patients in remission. Methods. RA patients were recruited in 2018 in the random order of presentation from the outpatient clinic. In the day of enrolment, all patients underwent clinical examination (by a senior rheumatologist, blind to other evaluations), inflammatory markers (e.g. C-reactive protein-CRP) and ankle ultrasound (performed and interpreted by a single rheumatologist with more than 7 years of experience). Results. The sample included 59 patients in DAS28CRP remission, 27 in SDAI remission and 20 in Boolean remission. Among these 3 categories of remission, overall clinical ankle involvement presented similar prevalence (revolving around 30%). On average, 77% of patients presented overall ultrasound ankle involvement among the 3 categories of remission, with similar frequencies of ankle joint synovial hypertrophy (SH; 33%), power Doppler (PD) positive joint SH (15%), ankle joint effusion (60%), ankle tenosynovitis (27%) and PD positive ankle tenosynovitis (15%). In the subgroup of RA patients in DAS28CRP remission, compared to patients without clinical or ultrasound ankle involvement, those with at least one involved ankle had a significantly higher median CRP (0.34 mg/dl versus 0.19 mg/dl, p = 0.042). Conclusion. Among RA patients in remission, regardless of its definition, clinical and ultrasound involvement of ankles is frequent. Clinical and ultrasound screening of ankles in RA patients in remission seems an appropriate strategy.

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Subclinical synovitis measured by ultrasound in rheumatoid arthritis patients with clinical remission induced by synthetic and biological modifying disease drugs

Cited by 9 publications

References 18 publications

Using a DAS28-CRP-steered treat-to-target strategy does not eliminate subclinical inflammation as assessed by ultrasonography in rheumatoid arthritis patients in longstanding clinical remission

Using a DAS28-CRP-steered treat-to-target strategy does not eliminate subclinical inflammation as assessed by ultrasonography in rheumatoid arthritis patients in longstanding clinical remission

Rheumatoid Arthritis Relapse and Remission – Advancing Our Predictive Capability Using Modern Imaging

Clinical and ultrasound ankle involvement in rheumatoid arthritis in remission

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