Treatment decisions should not be guided by ultrasound findings

Common treat-to-target approaches are equally effective compared with additional ultrasound exams for treatment guidance in early rheumatoid arthritis (RA) [1].

In the ARCTIC and the TaSER trials, a trend toward reduced radiographic progression was observed, when ultrasound was added to the assessment, though the ultrasound did not significantly increase benefit vs a treat-to-target strategy. “Patients who seem to have been successfully treated and are free of clinical signs and symptoms of disease may continue to develop permanent structural joint damage. There is a need to find better ways to identify these patients and prevent this development,” Dr Espen Haavardsholm (Diakonhjemmet Hospital, Oslo, Norway), explained the motivation for the presented study.

Data of 230 patients from the ARCTIC study was analysed to evaluate a possible advantage of incorporating ultrasound on the outcome of MRI inflammation or structural damage. Information about MRI at baseline and at least 1 follow-up was available in 116 patients of the ultrasound arm and 102 in the conventional management group. MRI scoring was performed using the OMERACT RA MRI Scoring System. Depending on the study arm, treatment targets were Disease Activity Score (DAS) <1.6 and no swollen joints with or without taking the presence of “no power-Doppler signal in any joint” into account. All patients were 18-75 years old and disease-modifying antirheumatic drug (DMARD)-naïve. Treatment escalation was equal for both groups, starting with methotrexate, moving to a combination with methotrexate/sulfasalazine/hydroxychloroquine, and to a biologic DMARD. In the ultrasound arm, sonography findings were the driver of stepping-up therapy, overruling DAS and swollen joint count. Changes from baseline were determined using a linear mixed model adjusted for possible confounders in terms of baseline score, age, gender, centre, and anti-cyclic citrullinated peptide antibody status.

No advantage in the ultrasound arm

Statistically significant differences between the 2 study groups were not detectable for the combined MRI scores. Results for mean combined MRI inflammation score at year 1 was -64.2 (ultrasound arm) versus -59.4 (treat-to-target arm; P=0.34). These levels did continue during the second year. Progression of erosive joint damage was seen in 39% of the ultrasound and 33% of the conventional group, resulting in a relative risk of 1.16 (P=0.40). In Dr Haavardsholm’s opinion, “the main message is that people with RA should be diagnosed and started on treatment early, monitored closely, and treatment should be stepped up aggressively until the target of clinical remission is reached. This strategy has proven very successful. However, going beyond this by aiming to also achieve imaging remission increases treatment cost and effort, but does not significantly further improve the result.“ The emerging body of evidence in RA does not support the use of imaging to guide therapy once the diagnosis is established and this has implications for clinical practice going forward.

1. 
   
   1. Sundin U et al. Abstract 280. ACR 2019. November 8-13, Atlanta (GA/USA).

Posted on 4 February 202012 March 2021