Examining Remission Targets for Patients with Rheumatoid Arthritis

Study finds ultrasound should be included in the management of RA patients in clinical remission.

Physicians can use ultrasound technology to identify patients with rheumatoid arthritis (RA) who are in remission but could benefit from more intensive treatment, researchers from Ospedale Mauriziano in Italy found.

The investigation team, which included members of the Musculoskeletal Ultrasound Study Group of the Italian Society of Rheumatology, tested the association between ultrasound-diagnosed synovitis and ultrasound-diagnosed tenosynovitis with the occurrence of exacerbations over a 6-month period in a population of RA patients in clinically defined remission as part of the STARTER study.

There were 427 patients involved in the study and each underwent a full clinical evaluation and ultrasound exam at the wrists, hand, and finger joints, and extensor/flexor tendon sheets. The researchers defined flares as an increase in the DAS 28 score of more than 1.2, or an increase in treatment, or a change of more than 4 points in the flare questionnaire.

The researchers additionally said that if the DAS 28 score was less than 3.2 at baseline, significant change of 0.6 qualified as an increase in the score. The researchers found that there was an association between ultrasound diagnosis of tenosynovitis and patient related flare and symptom exacerbation in symptom free patients.

The researchers added that this study was the first time a link was demonstrated. Secondly, the researchers determined that using high resolution ultrasounds in diagnosing synovitis, RA patients in clinical remission could be identified as patients that would benefit from more intense treatment. The more intense treatment would be able to prevent further joint damage.

Ultrasound positive synovitis was found in 75% of patients in clinical remission (101 patients out of 134 total) in a study testing the intensive treatment — the researchers in the SCRUM study added an increased dose of methotrexate or the patients enrolled stayed on their current methotrexate dose.

“Although the role of ultrasound diagnosed synovitis is well known in the literature, no data are available for tenosynovitis,” lead investigator Dr. Emanuela Bellis explained in a press release. “We have shown, for the first time, that an ultrasound diagnosis of tenosynovitis provides additional valuable information to the established use of ultrasound diagnosed subclinical synovitis; it should therefore be routinely included in the management of RA patients in clinical remission.”

The research was presented as two studies at the European League Against Rheumatism (EULAR) Annual Congress in Rome in June. The EULAR statement added that the organization recommends that remission is the target for RA treatment. Additionally, remission can be achieved more frequently through modern therapeutic strategies, it said.

Only about half of RA patients in remission experience a disease flare in the subsequent 24 months.