Background/Purpose: Intra-articular (IA) infliximab (IFX) is an attractive treatment option of chronic arthritis, but based on few heterogenic studies, outcome is still controversial. To investigate clinical response to IA IFX we used 3D/4D PD sonography adjacent to standard power doppler ultrasound (PDUS), clinical examination, juvenile disease activity scores (JADAS) and laboratory values (ESR, CRP). 

Methods: IA infliximab (50 or 25mg) was administered to 22 joints (20 knee joints, 1 radiocarpal and 1 talocrural) of 14 mono- or oligoarticular JIA patients treated with standard therapy (NSAID, DMARD, glucocorticoids). Clinical examination, JADAS and laboratory data (CRP, ESR) were obtained prior to every US examination. The Omecrat semiquantitative grades (0-3) for both B-mode and PD evaluation of each joint were obtained. Selected patients with knee joint arthritis were examined with 3D/4D US. Subsequently, VOCAL™ (Virtual organ Computer-aided AnaLysis) software was utilized to calculate volume of predesigned spheras in the five standardized positions adjusted for the IA size using a specially designed grid. The software automatically displayed sphere volume and three 3D indices: vascularization index (VI), flow index (FI) as well as vascularization and flow index (VFI). The indices are assumed to reflect the number of vessels within the volume of interest (VI), intensity of flow at the time of 3D sweep (FI), and both blood flow and vascularization (VFI), respectively. To compare indices, laboratory values and scores, as well as to analyze correlations, repeated measures ANOVA and Pearson’s test were used.

Results: At the time of IA injections all of the patients had the clinical signs of synovitis, average B-mode grade was 2,45 (±0,52), and average PD grade was 1,98 (±0,65). One month after IA infliximab, average B-mode grade was 1,32 (±0,41), average PD grade was 0,82 (±0,61) and there was no clinical signs of arthritis. Three months after, average B-mode grade was 1,09 (±0,91) and average PD grade was 0,82 (±1,08), with no clinical signs of arthritis. Mean value of B-mode grade, PD grade, JADAS and ESR was significantly lower (p<0,05) in all patients both one and three months after the treatment. 3D/4D US and VOCAL software were used for the analysis of 15 joints in 10 patients prior to IA injection and after the mean follow up time of 6,7 months (range 3-11). There was significant difference (p<0,05) in mean value of VI, FI, VFI and FI/SW before and after the treatment. We also observed significant correlation between VFI/SW and ESR, FI/SW and B mode grade, as well as between B mode grade, PD grade, JADAS, CRP and ESR. No local or systemic adverse reactions were noted.

Conclusion: IA IFX appears to be an effective and safe treatment option for the knee (and most likely other) joints in JIA patients refractory to the standard therapy. With 3D/4D US and the corresponding analytical software it is possible to quantify degree of vascularization and to obtain an objective measurements that can be used in recognition of necessity for therapeutic intervention as well as for monitoring the response. Further multicenter studies including larger number of patients and observer variability are needed.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/determination-of-efficacy-of-intra-articular-infliximab-therapy-in-jia-patients-by-3d4d-musculo-skeletal-ultrasound/