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Mouterde G, Lukas C, Filippi N, Marin G, Molinari N, Combe B, Morel J. Persistence of power Doppler ultrasonography-detected synovitis over 1 year of follow-up predicts poor prognosis in rheumatoid arthritis in clinical remission: the SONORE prospective longitudinal study. RMD Open 2024; 10:e004269. [PMID: 39289028 PMCID: PMC11409282 DOI: 10.1136/rmdopen-2024-004269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/22/2024] [Indexed: 09/19/2024] Open
Abstract
OBJECTIVES (1) To assess the progression of ultrasonography-detected synovitis in a cohort of patients with rheumatoid arthritis (RA) in remission during 1 year of follow-up (2) to evaluate the ability of consecutive examinations of ultrasonography to predict relapse (R) or radiographic progression (RP) at 1 year. METHODS Patients with RA (2010 American College of Rheumatology-European Alliance of Associations for Rheumatology criteria) in clinical remission (Disease Activity Score in 28 joints (DAS28)<2.6 without clinically active synovitis) were included. An independent investigator performed ultrasonography every 3 months for 1 year. Ultrasonography-detected synovitis was defined as power Doppler-positive ultrasonography synovitis (PDUS) grade ≥1 in at least one joint. PDUS at ≥2 consecutive visits during the follow-up defined persistent PDUS. An increase of ≥1 point in the modified total Sharp score defined RP. An increase in DAS28-C-reactive protein (CRP)>0.6 or DAS28-CRP>3.2 and any modification of disease-modifying anti-rheumatic drugs or glucocorticoids defined relapse. Univariate and multivariate Cox regression analyses were used to evaluate factors associated with R/RP at 1 year. RESULTS PDUS was detected in 75 (65.2%), 66, 60, 46 and 29 of the 115 patients with RA at baseline and at months 3, 6, 9 and 12, respectively. 58 (50.4%) patients exhibited persistent PDUS. After 1 year, 22/85 (25.9%) experienced relapse and 12 (14.1%) showed RP. On multivariate analysis, factors predicting R/RP at 1 year were persistent PDUS (HR=2.98, p=0.014) and an increase in DAS28-CRP level at the visit before relapse (HR=4.36, p=0.004). CONCLUSION Persistent PDUS during follow-up, rather than at baseline, predicted worse outcome at 1 year and requires careful monitoring.
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Affiliation(s)
- Gael Mouterde
- Rhumatologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
- University of Montpellier, Montpellier, Occitanie, France
| | - Cédric Lukas
- Rhumatologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
- University of Montpellier, Montpellier, Occitanie, France
| | - Nathalie Filippi
- Rhumatologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Gregory Marin
- Department of Statistics, University of Montpellier, Montpellier, Occitanie, France
| | | | - Bernard Combe
- Rhumatologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
- University of Montpellier, Montpellier, Occitanie, France
| | - Jacques Morel
- Rhumatologie, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
- University of Montpellier, Montpellier, Occitanie, France
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Yoshii I, Sawada N, Chijiwa T. Associations between clinical metrics of joint deformity, disease duration, disease activity, functional capacity, quality of life, pain, and fatigue in patients with rheumatoid arthritis. Clin Rheumatol 2023; 42:1027-1038. [PMID: 36371481 DOI: 10.1007/s10067-022-06432-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/13/2022] [Accepted: 11/01/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Aim of this study is to clarify associations between metrics of patient's clinical status statistically using retrospective cohort data. METHODS Patients with RA who were followed up more than 3 years were recruited. Their EuroQol-5th dimension (EQ5D) as an index of quality of life (QOL), Health Assessment Questionnaire Disability Index (HAQ) as an index of functional capacity (FC), simplified disease activity index (SDAI), pain score using visual analog scale (PS-VAS), and fatigue score using visual analog scale (FS-VAS) were monitored every three months. Sharp/van der Heijde score (SHS) was calculated annually. Associations between average values of these factors at beginning of follow-up (baseline) and change from baseline to final year in follow-up (change), and patient's sex, age, and disease duration (DD) were evaluated statistically. RESULTS A total of 447 patients were analyzed. EQ5D score correlated significantly with HAQ score both at baseline and change of that, and FS-VAS. HAQ score correlated significantly with EQ5D and HAQ score at baseline. SDAI score correlated significantly with SHS and FS-VAS at baseline. SHS correlated significantly with the SHS at baseline. PS-VAS correlated significantly with the PS-VAS, EQ5D at baseline, change of theEQ5D and HAQ scores. FS-VAS correlated significantly with change of the EQ5D score and FS-VAS at baseline. CONCLUSIONS These results suggested that these clinical metrics are influenced by each variable at baseline. QOL and fatigue are correlated each other, as well as QOL and FC, whereas disease activity correlated with joint deformity level and fatigue. Key Points • It is questionable whether improvement of disease activity leads to improvements in functional capacity and QOL in treating rheumatoid arthritis. • We evaluated the association among metrics of clinical outcomes, such as EQ5D, HAQ, SDAI, SHS, pain score, and fatigue score using retrospective cohort data. • Results suggested that metrics are influenced by each items at baseline, and QOL and fatigue are correlated each other, as well as QOL and functional capacity.
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Affiliation(s)
- Ichiro Yoshii
- Department of Musculoskeletal Medicine, Yoshii Hospital, 6-7-5 Nakamura-Ohashidori, Shimanto City, Kochi, 787-0033, Japan.
| | - Naoya Sawada
- Department of Rheumatology, Dohgo Onsen Hospital Rheumatology Center, 21-21 Himetsuka Otsu, Matsuyama, Ehime Prefecture, 790-0858, Japan
| | - Tatsumi Chijiwa
- Department of Rheumatology, Kochi Memorial Hospital, 4-13 Shiromi-Cho, Kochi, Kochi Prefecture, 780-0824, Japan
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Terslev L, Ostergaard M, Georgiadis S, Brahe CH, Ellegaard K, Dohn UM, Fana V, Møller T, Juul L, Huynh TK, Krabbe S, Ornbjerg LM, Glinatsi D, Røgind H, Hansen A, Nørregaard J, Jacobsen S, Jensen DV, Manilo N, Asmussen K, Boesen M, Rastiemadabadi Z, Morsel-Carlsen L, Møller JM, Krogh NS, Hetland ML. Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors. RMD Open 2022; 8:rmdopen-2022-002796. [PMID: 36549857 PMCID: PMC9791469 DOI: 10.1136/rmdopen-2022-002796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs). METHODS Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses. RESULTS Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007). CONCLUSION The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.
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Affiliation(s)
- L Terslev
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Ostergaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stylianos Georgiadis
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Cecilie Heegaard Brahe
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Karen Ellegaard
- The Parker Institute, Bispebjerg og Frederiksberg Hospital, Frederiksberg, Denmark
| | - UM Dohn
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Viktoria Fana
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Torsten Møller
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Lars Juul
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Tuan Khai Huynh
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Holte Rheumatology Clinic, Capital Region, Holte, Denmark
| | - Simon Krabbe
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - L M Ornbjerg
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Daniel Glinatsi
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Rheumatology, Skaraborg Hospital Skövde, Skovde, Sweden
| | - Henrik Røgind
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Annette Hansen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Jesper Nørregaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Søren Jacobsen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte V Jensen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Danbio Registry, Glostrup, Denmark
| | - Natalia Manilo
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Karsten Asmussen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Mikael Boesen
- Department of Radiology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | | | - Lone Morsel-Carlsen
- Department of Radiology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | | | | | - Merete Lund Hetland
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Parisi S, Zanetti A, Carrara G, Scirè CA, Iagnocco A, Filippou G. Relationship between the prevalence of subclinical tenosynovitis and treatment in patients with RA in clinical remission: STARTER study. Rheumatology (Oxford) 2022; 62:1485-1492. [PMID: 36066434 DOI: 10.1093/rheumatology/keac518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/04/2022] [Accepted: 08/30/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study is a sub-analysis from the patient cohort of the STARTER (Sonographic Tenosynovitis Assessment in RheumaToid arthritis patiEnts in Remission) study. The aim was to evaluate differences in ultrasound-detected joint and/or tendon involvement between patients receiving therapies based on a combination of csDMARDs and bDMARDs and those who were treated with either csDMARDs or bDMARDs in monotherapy. METHODS 427 consecutive patients with a diagnosis of rheumatoid arthritis were recruited between October 2013 and June 2014.They were divided into 3 subgroups based on their therapy at baseline: patients with bDMARDs in monotherapy, patients with csDMARDs in monotherapy, patients in combination therapy (csDMARD+bDMARD). At baseline, 6 months and 12 months, a clinical examination (28 joint count), an ultrasound evaluation were performed in each patient. A score of Grey Scale (GS) and Power Doppler (PD)-synovitis and -tenosynovitis, was calculated based on the OMERACT scoring systems. RESULTS 256 patients completed the observation period: 48 patients from the bDMARDs group (19.7%), 152 patients from the csDMARDs group (59.1%) and 56 pts from csDMARD+bDMARD group (21.8%).The analysis has shown that GS-tenosynovitis and PD-tenosynovitis are better controlled in combination therapy than they are with csDMARDs alone (p:0.025 and p:0.047, respectively); for PD synovitis, there was a better response in those who were treated with the combination therapy when compared to the patients in csDMARD (p:0.01) and those in bDMARD (p:0.02). CONCLUSION The analysis showed a lower prevalence of subclinical inflammatory manifestations detected with ultrasound imaging in those patients treated with the combination therapy than in those in monotherapy.
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Affiliation(s)
- Simone Parisi
- Rheumatology Unit, AOU Città Della Salute e della Scienza di Torino, Turin, Italy
| | - Anna Zanetti
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Carlo Alberto Scirè
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy.,School of Medicine, University of Milano Bicocca, Milan, Italy, Milan, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Georgios Filippou
- IRCCS Istituto Ortopedico Galeazzi, Department of Rheumatology, Milan, Italy
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Terslev L, Ostergaard M. Rheumatoid Arthritis Relapse and Remission - Advancing Our Predictive Capability Using Modern Imaging. J Inflamm Res 2021; 14:2547-2555. [PMID: 34163211 PMCID: PMC8215903 DOI: 10.2147/jir.s284405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/27/2021] [Indexed: 01/18/2023] Open
Abstract
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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Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Terslev L, Brahe CH, Hetland ML, Georgiadis S, Ellegaard K, Juul L, Huynh T, Døhn UM, Fana V, Møller T, Krabbe S, Ørnbjerg LM, Glinatsi D, Røgind H, Hansen A, Nørregaard J, Jacobsen S, Jensen DV, Manilo N, Asmussen K, Boesen M, Rastiemadabadi Z, Morsel-Carlsen L, Møller JM, Krogh NS, Østergaard M. Doppler ultrasound predicts successful discontinuation of biological DMARDs in rheumatoid arthritis patients in clinical remission. Rheumatology (Oxford) 2021; 60:5549-5559. [PMID: 33748831 DOI: 10.1093/rheumatology/keab276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the ability of ultrasound to predict successful tapering and successful discontinuation of biological disease-modifying anti-rheumatic drugs (bDMARDs) at 2-year follow-up in rheumatoid arthritis (RA) patients in sustained remission. METHODS Patients in sustained remission (DAS28-CRP≤2.6) and no radiographic progression the previous year tapered bDMARD according to a standardized regime. One-hundred-and-nineteen of these patients were included in this ultrasound sub-study. At baseline, clinical assessment, MRI, x-ray and ultrasound of 24 joints were performed. Ultrasound-detected synovitis was defined and scored 0-3 using the Outcome in Rheumatology (OMERACT) scoring system at joint level for both greyscale and Doppler activity. Sum scores for each ultrasound modality were calculated for 24 joints at patient level. Final state of treatment was assessed after 2 years. The predictive value of ultrasound measures for successful tapering and discontinuation at 2-year follow-up was assessed via logistic regression analyses. RESULTS Negative IgM-RF (OR = 0.29; 95% Confidence Interval (CI)=0.10-0.85; p = 0.024) and lower Doppler sum score of 24 joints (OR(95%CI)=0.44;(0.15-0.87); p = 0.014) were independent predictors for successful discontinuation of bDMARD at 2-year follow-up. The predictive value of Doppler sum score was independent of MRI findings. Previous numbers of bDMARDs were predictive of successful tapering (OR(95% CI)=0.58(0.35-0.91); p = 0.018), whereas ultrasound was not. Clinical parameters were not predictive for successful tapering/discontinuation. CONCLUSIONS Doppler sum score was an independent predictor for successful discontinuation of bDMARDs at 2-year follow-up - the odds for achieving successful discontinuation decreased by 56% per one-unit increase in Doppler sum score. Ultrasound could not predict successful tapering.
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Affiliation(s)
- Lene Terslev
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Heegaard Brahe
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Merete Lund Hetland
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO registry, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Stylianos Georgiadis
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Karen Ellegaard
- The Parker Institute, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Lars Juul
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Tuan Huynh
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Holte Rheumatology Clinic, Capital Region, Denmark
| | - Uffe Møller Døhn
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Viktoria Fana
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Torsten Møller
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Simon Krabbe
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Lykke Midtbøll Ørnbjerg
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Daniel Glinatsi
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Rheumatology, Skaraborg Hospital, Skövde, Sweden
| | - Henrik Røgind
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Anette Hansen
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Jesper Nørregaard
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Søren Jacobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorte Vendelbo Jensen
- DANBIO registry, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Natalia Manilo
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Frederiksberg, Rigshospitalet, Capital Region, Denmark
| | - Karsten Asmussen
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Frederiksberg, Rigshospitalet, Capital Region, Denmark
| | - Mikael Boesen
- Department of Radiology, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Lone Morsel-Carlsen
- Department of Radiology, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | | | | | - Mikkel Østergaard
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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7
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Terslev L, Brahe CH, Østergaard M, Fana V, Ammitzbøll-Danielsen M, Møller T, Krabbe S, Hetland ML, Døhn UM. 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. Arthritis Res Ther 2021; 23:48. [PMID: 33522948 PMCID: PMC7849184 DOI: 10.1186/s13075-021-02426-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
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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Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Heegaard Brahe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Viktoria Fana
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Mads Ammitzbøll-Danielsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Torsten Møller
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Simon Krabbe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Uffe Møller Døhn
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
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Ozer PK, Sahin O, Ozer Z, Cengiz AK, Durmaz Y, Kaptanoglu E. Ultrasound-defined remission for good functional status in rheumatoid arthritis. Indian J Med Res 2018; 146:230-236. [PMID: 29265024 PMCID: PMC5761033 DOI: 10.4103/ijmr.ijmr_548_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background & objectives: It has been shown that joint damage due to subclinical synovitis progresses despite apparent clinical remission in rheumatoid arthritis (RA). Hence, finding more objective methods to investigate subclinical synovitis has become a current issue. Ultrasonography (US) has been among the most investigated methods. This study was conducted to detect whether there was subclinical inflammation in RA patients in clinical remission by power Doppler ultrasonography (PDUS) and to evaluate the effects of this inflammation on upper extremity function. Methods: Forty five RA patients fulfilled the remission criteria of disease activity score 28 using erythrocyte sedimentation rate (DAS28-ESR), were enrolled in the study. Bilateral wrist, 2nd and 3th metacarpophalangeal and proximal interphalangeal joints and 2nd and 5th metatarsophalangeal joints were examined by PDUS. Upper extremity function was assessed with Michigan Hand Outcomes Questionnaire (MHQ) and handgrip strength. The pain was evaluated by visual analogue scale (VAS). Results: In 29 of 45 RA patients in clinical remission, synovitis was detected by PDUS at least in one joint. VAS and DAS28-ESR scores were significantly lower and total MHQ, some subgroup scores of MHQ (overall hand function, activity of daily living and work performance) and grip strength of the dominant hand were higher in patients with PD signal negativity. Interpretation & conclusions: PDUS showed a crucial role in determining the subclinical synovitis. Subclinical synovitis negatively affects the upper extremity function. Ultrasound-defined remission may be considered for good functional status and real remission in patients with RA.
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Affiliation(s)
- Pinar Kaplan Ozer
- Department of Physical Medicine & Rehabilitation, Sivas State Hospital, Sivas, Turkey
| | - Ozlem Sahin
- Department of Physical Medicine & Rehabilitation, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Zafer Ozer
- Department of Physical Medicine & Rehabilitation, Sivas Numune Hospital, Sivas, Turkey
| | - Ahmet Kivanc Cengiz
- Department of Physical Medicine & Rehabilitation, Division of Rheumatology, Sivas Numune Hospital, Sivas, Turkey
| | - Yunus Durmaz
- Department of Physical Medicine & Rehabilitation, Division of Rheumatology, Mehmet Akif Inan Education & Research Hospital, Sanliurfa, Turkey
| | - Ece Kaptanoglu
- Department of Physical Medicine & Rehabilitation, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
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Simpson E, Hock E, Stevenson M, Wong R, Dracup N, Wailoo A, Conaghan P, Estrach C, Edwards C, Wakefield R. What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-258. [PMID: 29712616 PMCID: PMC5949573 DOI: 10.3310/hta22200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). OBJECTIVE To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. DATA SOURCES Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. REVIEW METHODS A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. MATHEMATICAL MODEL A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated. RESULTS Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used. LIMITATIONS Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed. CONCLUSION Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017216. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Philip Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| | - Cristina Estrach
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Edwards
- National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
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Grassi W, Okano T, Di Geso L, Filippucci E. Imaging in rheumatoid arthritis: options, uses and optimization. Expert Rev Clin Immunol 2015; 11:1131-46. [DOI: 10.1586/1744666x.2015.1075395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Factors influencing ultrasonographic remission in patients with rheumatoid arthritis. Rheumatol Int 2014; 35:485-91. [DOI: 10.1007/s00296-014-3177-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 11/10/2014] [Indexed: 12/18/2022]
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Ben Abdelghani K, Miladi S, Souabni L, Kassab S, Chekili S, Laatar A, Zakraoui L. Role of ultrasound in assessing remission in rheumatoid arthritis. Diagn Interv Imaging 2014; 96:3-10. [PMID: 25220573 DOI: 10.1016/j.diii.2014.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Remission is the ultimate goal of the treatment of rheumatoid arthritis (RA). However, the diagnosis of remission might still be vague. Musculoskeletal ultrasound (US) seems to effectively assess synovitis, effusion and bone damage. Thus, its role could be relevant for the diagnosis, monitoring or detection of relapse in the follow-up of RA in remission. The goal of this review of the literature was to clarify the added value of ultrasonography during remission. METHODS A systemic search of the literature was performed on Medline and Scopus. The following key words were used: rheumatoid arthritis, remission, US. Fifty-six papers were collected, then after an in depth analysis, twelve articles were selected for analysis. RESULTS Twelve papers were identified that assessed remission in RA. Remission criteria varied from one author to another. The number of joints assessed by US varied from six to 44 with the wrist and metacarpo-phalangeal joints of the dominant hand scanned at least. Irrespective of remission criteria, all authors demonstrated that US detected Doppler positive synovitis in patients in clinical remission. Also, power Doppler synovitis predicted structural damage and future flares of RA. CONCLUSION US seems to be more effective than a clinical exam. True remission in RA must be defined. Moreover, the inclusion of this technique in the new definition of remission is being validated.
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Affiliation(s)
| | - S Miladi
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia.
| | - L Souabni
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia
| | - S Kassab
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia
| | - S Chekili
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia
| | - A Laatar
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia
| | - L Zakraoui
- Rheumatology department, Mongi Slim hospital, la Marsa, Tunisia
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Nguyen H, Ruyssen-Witrand A, Gandjbakhch F, Constantin A, Foltz V, Cantagrel A. Prevalence of ultrasound-detected residual synovitis and risk of relapse and structural progression in rheumatoid arthritis patients in clinical remission: a systematic review and meta-analysis. Rheumatology (Oxford) 2014; 53:2110-8. [DOI: 10.1093/rheumatology/keu217] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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