Value of MRI and ultrasound for prediction of therapeutic response and erosive progression in patients with early rheumatoid arthritis managed by an aggressive treat-to-target strategy

The Clinical Utility of Musculoskeletal Ultrasound for Disease Activity Evaluation and Therapeutic Response Prediction in Rheumatoid Arthritis Patients: A Narrative Review

Rheumatoid arthritis (RA) is characterized by persistent synovitis and joint/bone destruction. There is an unmet need to predict the therapeutic response to disease-modifying anti-rheumatic drugs (DMARDs) and achieve a treat-to-target goal. Musculoskeletal ultrasound (MSUS) is widely used to identify structural change and assess therapeutic response in RA. This review aims to summarize the available evidence regarding the clinical application of MSUS in evaluating disease activity and predicting therapeutic responses to DMARDs. We searched the MEDLINE database using the PubMed interface and reviewed English-language literature from 2000 to 2022. This review focuses on the updated role of MSUS in assessing disease activity and predicting therapeutic responses to DMARDs in RA patients. MSUS is now widely applied to identify articular structural change and assess the disease activity of RA. Combined use of gray scale and power Doppler MSUS is also superior to clinical assessment and laboratory examination in evaluating disease activity of RA. With portable use, good viability, and high sensitivity to articular inflammation, MSUS would be useful in assessing therapeutic response to biologic/targeted synthetic DMARDs (b/tsDMARDs) in RA patients. Given MSUS could also detect subclinical inflammation in a substantial proportion of RA patients with clinical remission, it is recommended to assess b/tsDMARDs-treated RA patients who have achieved low disease activity or remission. Although substantial literature data have revealed clinical utility of MSUS for monitoring disease activity and evaluating therapeutic response in RA patients, the evidence regarding its predictive value for the effectiveness of b/tsDMARDs is limited.

RANet: a custom CNN model and quanvolutional neural network for the automated detection of rheumatoid arthritis in hand thermal images

Rheumatoid arthritis is an autoimmune disease which affects the small joints. Early prediction of RA is necessary for the treatment and management of the disease. The current work presents a deep learning and quantum computing-based automated diagnostic approach for RA in hand thermal imaging. The study's goals are (i) to develop a custom RANet model and compare its performance with the pretrained models and quanvolutional neural network (QNN) to distinguish between the healthy subjects and RA patients, (ii) To validate the performance of the custom model using feature selection method and classification using machine learning (ML) classifiers. The present study developed a custom RANet model and employed pre-trained models such as ResNet101V2, InceptionResNetV2, and DenseNet201 to classify the RA patients and normal subjects. The deep features extracted from the RA Net model are fed into the ML classifiers after the feature selection process. The RANet model, RA Net+ SVM, and QNN model produced an accuracy of 95%, 97% and 93.33% respectively in the classification of healthy groups and RA patients. The developed RANet and QNN models based on thermal imaging could be employed as an accurate automated diagnostic tool to differentiate between the RA and control groups.

Clinical prediction models of rheumatoid arthritis and its complications: focus on cardiovascular disease and interstitial lung disease

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease of unknown etiology with erosive, symmetric polyarthritis as the main clinical manifestations. Its basic pathological changes are the formation of synovitis, and patients gradually develop destruction of articular cartilage destruction and bone erosion, which eventually leads to joint deformity, disability, and various extra-articular manifestations. Clinical prediction models (CPMs), also known as risk prediction models or risk scores, are mathematical formulas used to estimate the probability that a given individual will have a disease or an outcome in the future. The models are mainly divided into two categories: diagnostic models and prognostic models, which can be used to provide information on disease diagnosis or prognosis to help make better medical decisions. Currently, there is no cure for RA, but effective early diagnosis and treatment are crucial for limiting the severity of the disease and preventing the occurrence and development of complications. This paper reviews the CPMs associated with RA and its related complications, including cardiovascular disease (CVD) and interstitial lung disease (ILD), in order to provide reference and evidence for the early diagnosis and treatment of these diseases and personalized medicine for patients. In addition, the possible pathogenesis and risk factors of these comorbidities are summarized, and possible directions for future related research are prospected.

Disproportionate articular pain is a frequent phenomenon in rheumatoid arthritis and responds to treatment with sarilumab

OBJECTIVES

In some patients with RA, joint pain is more severe than expected based on the amount of joint swelling [referred to as disproportionate articular pain (DP)]. We assessed DP prevalence and the effects of sarilumab, an IL-6 inhibitor, on DP.

METHODS

Data from RA patients treated with placebo or 200 mg sarilumab in the phase 3 randomized controlled trials (RCTs) MOBILITY and TARGET, adalimumab 40 mg or sarilumab 200 mg in the phase 3 RCT MONARCH and sarilumab 200 mg in open-label extensions (OLEs) were used. DP was defined as an excess tender 28-joint count (TJC28) over swollen 28-joint count (SJC28) of ≥7 (TJC28 - SJC28 ≥ 7). Treatment response and disease activity were determined for patients with and without DP.

RESULTS

Of 1531 sarilumab 200 mg patients from RCTs, 353 (23%) had baseline DP. On average, patients with DP had higher 28-joint DAS using CRP (DAS28-CRP) and pain scores than patients without DP, whereas CRP levels were similar. After 12 and 24 weeks, patients with baseline DP treated with sarilumab were more likely to be DP-free than those treated with placebo or adalimumab. In RCTs, more sarilumab-treated patients achieved low disease activity vs comparators, regardless of baseline DP status. In OLEs, patients were more likely to lose rather than gain DP status.

CONCLUSION

About one-quarter of patients with RA experienced DP, which responded well to sarilumab. These data support the concept that other mechanisms (potentially mediated via IL-6) in addition to inflammation may contribute to DP in RA.

TRIAL REGISTRATIONS

NCT01061736, NCT02332590, NCT01709578, NCT01146652.

ROCK inhibition with Y-27632 reduces joint inflammation and damage in serum-induced arthritis model and decreases in vitro osteoclastogenesis in patients with early arthritis

Rheumatoid arthritis (RA) is a common chronic inflammatory disease affecting primarily peripheral joints, which is only partially controlled with current treatments. RA leads to pain, disability, deformities, and life expectancy shortening. Its pathogenesis is complex involving multiple cell types and signaling pathways that we incompletely understand. One of the pathways we have elucidated starts with WNT5A signaling and contributes to the aggressive phenotype of the RA synoviocytes through RYK-RhoA/ROCK signaling. Now, we have explored the contribution of ROCK to arthritis in vivo, using the K/BxN serum-transfer arthritis model; and to osteoclastogenesis, using the arthritis model and cells from patients with inflammatory arthritis. The mice and cells were treated with the ROCK inhibitor Y-27632 that caused a significant improvement of arthritis and reduction of osteoclastogenesis. The improvement in mouse arthritis was observed in the clinical evaluation and, histologically, in synovial inflammation, cartilage damage, bone erosion, and the abundance of multinucleated TRAP+ cells. Expression of inflammatory mediators in the arthritic joints, as assessed by real-time PCR, was also significantly reduced. The effect on bone was confirmed with in vitro assays using bone marrow precursors of arthritic mice and peripheral blood monocytes of patients with inflammatory arthritis. These assays showed dramatically reduced osteoclastogenesis and bone resorption. Overall, our findings suggest that ROCK inhibition could be part of a therapeutic strategy for RA by its dual action on inflammation and bone erosion.

Assessment of inflammation in patients with rheumatoid arthritis using thermography and machine learning: a fast and automated technique

Objectives

Sensitive detection of joint inflammation in rheumatoid arthritis (RA) is crucial to the success of the treat-to-target strategy. In this study, we characterise a novel machine learning-based computational method to automatically assess joint inflammation in RA using thermography of the hands, a fast and non-invasive imaging technique.

Methods

We recruited 595 patients with arthritis and osteoarthritis, as well as healthy subjects at two hospitals over 4 years. Machine learning was used to assess joint inflammation from the thermal images of the hands using ultrasound as the reference standard, obtaining a Thermographic Joint Inflammation Score (ThermoJIS). The machine learning model was trained and tuned using data from 449 participants with different types of arthritis, osteoarthritis or without rheumatic disease (development set). The performance of the method was evaluated based on 146 patients with RA (validation set) using Spearman’s rank correlation coefficient, area under the receiver-operating curve (AUROC), average precision, sensitivity, specificity, positive and negative predictive value and F1-score.

Results

ThermoJIS correlated moderately with ultrasound scores (grey-scale synovial hypertrophy=0.49, p<0.001; and power Doppler=0.51, p<0.001). The AUROC for ThermoJIS for detecting active synovitis was 0.78 (95% CI, 0.71 to 0.86; p<0.001). In patients with RA in clinical remission, ThermoJIS values were significantly higher when active synovitis was detected by ultrasound.

Conclusions

ThermoJIS was able to detect joint inflammation in patients with RA, even in those in clinical remission. These results open an opportunity to develop new tools for routine detection of joint inflammation.

The Programmed Death-1 Pathway Counter-Regulates Inflammation-Induced Osteoclast Activity in Clinical and Experimental Settings

Objective

The programmed death-1 (PD-1) pathway is essential for maintaining self-tolerance and plays an important role in autoimmunity, including rheumatoid arthritis (RA). Here, we investigated how membrane-bound and soluble (s)PD-1 influence bone homeostasis during chronic inflammation, exemplified in RA.

Methods

Bone mineral density and bone microstructure were examined in PD-1 and PD-L1 knockout (KO) mice and compared with wild-type (WT) mice. Receptor activator of nuclear factor kappa-B ligand (RANKL) was measured in serum, and the expression examined on activated bone marrow cells. Osteoclast formation was examined in cells from murine spleen and bone marrow and from human synovial fluid cells. sPD-1 was measured in chronic and early (e)RA patients and correlated to markers of disease activity and radiographic scores.

Results

PD-1 and PD-L1 KO mice showed signs of osteoporosis. This was supported by a significantly reduced trabecular bone volume fraction and deteriorated microstructure, as well as increased osteoclast formation and an increased RANKL/OPG ratio. The recombinant form of sPD-1 decreased osteoclast formation in vitro, but was closely associated with disease activity markers in eRA patients. Sustained elevated sPD-1 levels indicated ongoing inflammation and were associated with increased radiographic progression.

Conclusion

The PD-1 pathway is closely associated with bone homeostasis, and lacking members of this pathway causes a deteriorated bone structure. The immunological balance in the microenvironment determines how the PD-1 pathway regulates osteoclast formation. In eRA patients, sPD-1 may serve as a biomarker, reflecting residual but clinically silent disease activity and radiographic progression.

Importance of baseline musculoskeletal ultrasound findings in the prognosis of rheumatoid arthritis

OBJECTIVES

To investigate the prognostic value of baseline musculoskeletal ultrasound (MSUS) findings for rheumatoid arthritis (RA).

METHOD

We retrospectively analyzed 138 patients with RA. Patients' first MSUS record was considered as the baseline expression. The subsequent MSUS changes that showed alleviation or progression were regarded as the cutoff point. Grayscale ultrasound (GSUS) synovitis, power Doppler ultrasound (PDUS) synovitis, PDUS tenosynovitis (TS), and bone erosion were scored using a semi-quantitative scale. According to the ultrasound (US) results of the cutoff point, patients were divided into the alleviation group and the progression group. Laboratory results (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], rheumatoid factor [RF], anticyclic citrullinated peptide [anti-CCP] antibody, and anti-keratin antibody [AKA]), disease activity score in 28 joints (DAS28)-ESR, and US scores were compared between the two groups to analyze the prognostic value of US findings in RA.

RESULTS

The alleviation group had higher levels of CRP, synovitis, TS, GSUS synovitis, PDUS synovitis, PDUS TS, and US total scores at baseline than the progression group (p < 0.05). The alleviation group received more aggressive treatment in their initial approach than the progression group (p < 0.05). The frequency of US examinations in the alleviation group was more than that in the progression group at follow-up (p < 0.05). Presence of baseline synovitis (OR 0.248, p = 0.006) and a higher GSUS synovitis score (OR 0.521, p = 0.006) were negatively correlated with RA progression.

CONCLUSIONS

Presence of baseline synovitis and higher GSUS synovitis score do not always indicate worse prognosis of RA, which can be improved with aggressive treatment. Regular MSUS follow-up may have positive influences on prognosis. Key Points • The presence of synovitis at baseline and higher GSUS synovitis score do not necessarily imply poor prognosis of RA. • Prompt and powerful therapy and regular ultrasound follow-up can slow down the progression of RA and improve its prognosis. • Patients with slight and less arthritis at baseline might be ignored and get worse prognosis due to mild treatment strategies and irregular MSUS examination.

The role of whole-body MRI in musculoskeletal inflammation detection and treatment response evaluation in inflammatory arthritis across age: A systematic review

OBJECTIVE

To evaluate the relation between whole-body MRI (WBMRI) outcomes and disease activity measures, including clinical examination, composite scores, and other imaging outcomes, and the ability of WBMRI to detect treatment response in patients with inflammatory arthritis (IA) across age.

METHODS

Human studies published as full text or abstract in the PubMed and MEDLINE and Cochrane databases from inception to 11th April 2021 were systematically and independently searched by two reviewers. Studies including patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) or unclassified inflammatory arthritis (UA) who underwent WBMRI and which reported on disease outcomes were included.

RESULTS

Nineteen full-text studies were eligible for inclusion: 2 interventional, 7 retrospective and 10 prospective observational studies, comprising 540 participants (SpA 38.7%, RA 24.8%, JIA 17.8%, PsA 11.5%, healthy controls 5.9%, UA 1.3%). Abstracts of 6 conference papers were reported separately. Five studies in PsA and SpA and 4 in RA measured the frequency of WBMRI-detected and clinically-detected synovitis, and all found the former to be more frequent. Less enthesitis was detected by WBMRI than clinical examination in 5/8 studies. After biologic treatment, the WBMRI inflammation scores declined in 3 studies in SpA and 2 in RA, whilst in 3 studies the results were equivocal.

CONCLUSION

The ability of WBMRI to assess disease activity and treatment response in IA was adequate overall. Further studies are needed to corroborate WBMRI findings with IA outcomes and investigate the clinical value of subclinical inflammation.

A treat-to-target approach is needed for Behçet's syndrome

PURPOSE OF REVIEW

Treat-to-target (T2T) approach has improved outcomes in chronic diseases. The aim of this review is to discuss the long-term goals and review the evidence for possible targets that would predict the achievement of these goals for developing a T2T strategy for Behçet's syndrome.

RECENT FINDINGS

There are no trials comparing a tight control strategy to standard care in Behçet's syndrome but recent studies suggest better outcomes with earlier use of biologic agents compared with sustained conventional treatment. Fluorescein angiography may be a reliable tool for assessing remission in uveitis as fluorescein angiography findings were shown to predict relapses and long-term visual outcome. Good recanalization on Doppler ultrasonography can be a target for venous involvement as this was the only predictor of relapse. Fecal calprotectin levels were associated with small intestinal and colonic ulcers and may be used as a surrogate for remission of gastrointestinal involvement.

SUMMARY

There are several new treatment modalities that are tried for Behçet's syndrome and ongoing work on outcome measures for reliable disease assessment. In order to ensure the wise and efficient use of treatment modalities, development and implementation of T2T strategies are needed through multidisciplinary and multinational efforts that include patient research partners.

CXCL13 predicts long term radiographic status in early rheumatoid arthritis

OBJECTIVES

It remains challenging to identify rheumatoid arthritis (RA) patients at a high risk of joint destruction. The C-X-C motif chemokine 13 (CXCL13) has previously been suggested as a marker of disease activity in RA. Here, we investigate the potential of plasma CXCL13 as a marker of long-term radiographic status and progression.

METHODS

CXCL13 was measured in plasma from treatment naïve RA patients (n = 158) with 11-year follow-up. At baseline, clinical and biochemical disease activity scores were obtained; among these C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), disease activity score in 28 joints with CRP(DAS28CRP), number of, swollen joints (SJC28) and radiographic status, evaluated by total Sharp score (TSS). Age and gender matched healthy controls (HC) were included.

RESULTS

CXCL13 was significantly increased at baseline and decreased during treatment, however without reaching the level in HC. At baseline, CXCL13 was associated with both CRP and ESR, but not with other markers of disese activity. Baseline CXCL13 correlated with both TSS and radiographic progression (ΔTSS) at 11 years. With a 89% probability, levels of CXCL13 above 85 pg/ml predicted the risk of a TSS of 5 or above, after 11 years of treatment. Comparing with CRP, DAS28CRP, SJC28 and anti-citrullinated peptide antibody status, CXCL13 was superior in predicting 11-year joint destruction.

CONCLUSION

In early RA, one single measurement of plasma CXCL13 at baseline, is superior to currently used clinical and serological disease markers, to predict longterm radiographic status and progression.

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

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.