Background/Purpose: The latest recommendations for the treatment of rheumatoid arthritis (RA) focus on the achievement of clinical remission. However, joints with subclinical positive power Doppler (PD) signals in ultrasonography (US) might be exposed to the risk of joint damage progression even after the achievement of clinical remission. The aim of this study was to assess subclinical synovitis by US and evaluate the effects of additional intensive treatment for preventing joint damage among RA patients in clinical remission.

Methods:

This study was based on the SCRUM (suppress the joint destruction in clinical remission patients who have active synovitis of ultrasonographic assessment by increasing the dose of methotrexate) study, an open-label, randomized trial. US examination was performed consecutively for 134 patients with RA in clinical remission defined as DAS (Disease activity score) 28<2.6. US assessment was performed at 34 synovial sites in 30 joints. The gray scale (GS) and PD signals were scored in each joint using a semi-quantitative scale from 0 to 3. According to the results of US assessment, the patients with PD positive synovitis (PD³1 in at least one joint) were randomly assigned to two groups; the patients increased the dose of MTX (intensive treatment group) or the patients continue their current treatment (coutinuous treatment group). The patients without active synovitis continued their current treatment (PD negative group). Standard radiographs of hands and forefeet were obtained at baseline, week 24 and 52. Radiological joint damage was assessed according to the modified total Sharp score (mTSS). The primary endpoint of the study was a change of mTSS after 52 weeks compared to the baseline.

Results:

Of 134 patients with clinical remission, PD positive synovitis was found in 101 patients (75.4%) at baseline. After the randomization, 51 patients were assigned to intensive treatment group and 50 patients to coutinuous treatment group. Thirty-seven patients in intensive treatment group (72.5%), 42 patients in coutinuous treatment group (84%) and 20 patients in PD negative group (60.6%) completed this study until week 52. Total PD score was significantly decreased inintensive treatment group comparing to coutinuous treatment group (-3.9 vs -2.0, p=0.019). The progression of mTSS was significantly suppressed in intensive treatment group compared to coutinuous treatment group at both week 24 (0.27 and 1.02, p=0.007) and week 52 (1.03 and 2.02, p=0.038). Especially, the progression of mTSS in patients treated with biologics in intensive treatment group (n=16) was suppressed as same as PD negative group (0.75 and 0.80, respectively) at week 52.

Conclusion:

In conclusion, clinical remission according to composite indexes allowed the presence of subclinical active synovitis that might induce structural joint damages. Subclinical active synovitis should be controlled by additional treatment and this results in the prevention of the joint damage progression. Evaluation of subclinical active synovitis by using high resolution US should be important even in patients achieving clinical remission and it should be treated more intensively.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/additional-intensive-treatment-for-rheumatoid-arthritis-patients-with-positive-power-doppler-signals-reduce-the-radiological-joint-damage-even-after-achieving-clinical-remission-scrum-study/