Session Information
Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose:
Tenosynovitis has been regarded as a feature of RA, although its true prevalence in early stages has not been firmly established. The aim of this work was to evaluate US findings of tenosynovitis in a cohort of ACPA+ patients.
Methods:
Consecutive ACPA+ patients, without clinical synovitis (CS), underwent US of 9-paired tendons and 24-paired joints. Baseline assessment included: 1) demographic/clinical characteristics, 2) extensor carpi ulnaris and flexor tendons gray-scale (GS) and power-doppler (PD), 3) joint GS, PD and erosions. US findings were assessed with the OMERACT semi-quantitative score. χ2/Fisher’s exact test for categorical and Student-t test/Mann-Whitney for continuous variables, were used to identify differences regarding the prevalence of US tenosynovitis, synovitis or progression to CS.
Results:
A total of 146 individuals were included (71% women, mean(SD) age of 50(14) years) with 17 (11.6%) progressing to CS (all RA). This was predicted by the duration of early morning stiffness (p<.01), presence of shared epitope (p=.02) and high titres of RF(p<.01) and anti-CCP (p<.01) (table 1). The median (IQR) time to progression of CS was 6.5 (4.3-10.5) months.
Twenty subjects (13.7%) had changes of GS and/or PD tenosynovitis, the majority classified as GS=1. A positive trend was found towards the progression to CS [OR (95%)=3.2 (1.0-10.2), p=.06]. The same association was seen between US synovitis and CS, with higher OR when PD was ≥2 [OR(95%)=4.2 (0.7-24.7), p=.15] (table 2).
Of those 20 individuals, 7 had concomitant US synovitis in the respective anatomical joints. Even though a correlation between significant US synovitis (GS≥2 and/or PD≥1) and tenosynovitis (any finding) was not found, an association was seen for the subgroup of patients who presented only with PD synovitis [OR (95%CI)=4.5 (1.4-14.0), p=.01]. This was reinforced when only PD≥2 synovitis was considered [OR (95%CI)=15.5 (2.6-91.5), p<.01]. Tenosynovitis was anatomically separate to synovitis with one exception.
Finally, tenosynovitis was not significantly associated with any of the demographic or clinical characteristics.
Conclusion:
To our knowledge this is the first study to assess tenosynovitis in a large cohort of ACPA+ patients; a low prevalence and a positive trend towards the progression to CS were found. The low prevalence of progression to CS and the absence of its association with US synovitis may suggest that this could represent the earliest stage of disease. Further studies with larger samples and with other methods (e.g. MRI) are warranted to confirm these results.
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Table 1. Baseline demographic and clinical characteristics of ACPA+ individuals and those with progression to CS |
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Total patients (n=146) |
Patients with progression to CS (n=17) |
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Age |
Years (mean (SD)) |
49.94 (14.12) |
55.15 (16.03) |
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Gender |
Female |
71.2% (104/146) |
58.8% (10/17) |
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Symptom duration |
Months (median (IQR)) |
14.33 (7.42-60.23) |
12.43 (5.33-59.90) |
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Sudden symptom onset |
Yes |
38.1% (51/134) |
41.2% (7/17) |
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EMS |
Minutes (median (IQR)) ≥30min |
0.00 (0.00-52.50) 34.8% (49/141) |
60.00 (2.50-120.00) 70.6% (12/17) |
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FDR with RA |
Yes |
20.5% (30/146) |
29.4% (5/17) |
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BMI |
Kg/m2 (mean (SD)) |
28.99 (6.05) |
29.11 (7.22) |
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Smoker |
Ever |
60.2% (80/133) |
76.5% (13/17) |
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Alcohol consumer |
Yes |
60.0% (78/130) |
76.5% (13/17) |
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No. of painful joints |
0 to 18 (median (IQR)) |
4 (2-8) |
5 (3-8) |
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Localization of patient-reported joint symptoms |
None Small joints only Large joints only Small and large joints |
9.6% (13/136) 16.9% (23/136) 11.0% (15/136) 62.5% (85/136) |
11.8% (2/17) 23.5% (4/17) 0% (0/17) 65.7% (11/17) |
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Localization of patient-reported joint symptoms in extremities |
None Upper only Lower only Upper and lower |
9.6% (13/136) 14.7% (20/136) 12.5% (17/136) 63.2% (86/136) |
11.8% (2/17) 11.8% (2/17) 0% (0/17) 76.5% (13/17) |
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Symmetry of patient-reported joint symptoms |
None Symmetrical Asymmetrical |
9.6% (13/136) 65.4% (89/136) 25.0% (34/136) |
11.8% (2/17) 64.7% (11/17) 23.5% (4/17) |
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No. of tender joints |
TJC28 (median (IQR)) RAI (median (IQR)) |
0 (0-2) 1 (0-3) |
1 (0-4) 2 (0-4.5) |
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Localization of clinical joint tenderness |
None Small joints only Large joints only Small and large joints |
46.2% (66/143) 29.4% (42/143) 10.5% (15/143) 14.0% (20/143) |
29.4% (5/17) 47.1% (8/17) 0% (0/17) 23.5% (4/17) |
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Localization of clinical joint tenderness in extremities |
None Upper only Lower only Upper and lower |
46.2% (66/143) 21.0% (30/143) 11.2% (16/143) 21.7% (31/143) |
29.4% (5/17) 23.5% (4/17) 5.9% (1/17) 41.2% (7/17) |
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Symmetry of clinical joint tenderness |
None Symmetrical Asymmetrical |
46.2% (66/143) 27.3% (39/143) 26.6% (38/143) |
29.4% (5/17) 41.2% (7/17) 29.4% (5/17) |
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Shared epitope |
None One copy Two copies |
37.4% (40/107) 44.9% (48/107) 17.8% (19/107) |
11.8% (2/17) 64.7% (11/17) 23.5% (4/17) |
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Anti-CCP |
Low positive High positive |
35.9% (51/142) 64.1% (91/142) |
5.9% (1/17) 94.1% (16/17) |
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RF |
Low positive High positive Negative |
18.0% (25/139) 19.4% (27/139) 62.6% (87/139) |
25.0% (4/16) 56.3% (9/16) 18.8% (3/16) |
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hsCRP |
Level (mg/dl) (median (IQR)) ≥2mg/dl |
1.66 (0.49-4.28) 48.9% (44/90) |
3.78 (0.87-7.75) 64.3% (9/14) |
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ESR |
Level (mm/h) (median (IQR)) |
12.00 (6.00-24.25) |
17.00 (6.00-42.75) |
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Pain VAS |
Level (0 to 100mm) (median (IQR)) |
25.00 (8.25-48.75) |
20.00 (6.00-33.00) |
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PGA – GH |
Level (0 to 100mm) (median (IQR)) |
21.50 (7.25-43.75) |
20.00(7.00-34.00) |
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Fatigue |
Level (0 to 100mm) (median (IQR)) |
29.00 (8.00-59.00) |
11.00 (8.00-62.00) |
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HAQ-DI |
Level (0 to 3) (median (IQR)) |
0.25 (0.00-0.63) |
0.25 (0.00-0.75) |
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CS: clinical synovitis; EMS: early morning stiffness; FDR: first degree relative; RA: Rheumatoid Arthritis; BMI: body mass index; RF: rheumatoid factor; hsCRP: high sensitivity C-reactive protein; ESR: erythrocyte sedimentation rate; VAS: visual analogue scale; PGA-GH: patient global assessment; HAQ-DI: health assessment questionnaire disability index. The status of high-level RF or anti-CCP was defined according to the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2010 criteria by a cut-off level of > 3 timed the upper limit of normal. hsCRP was performed and levels ≥ 2mg/l, which have been associated with disease activity in RA, were considered positive. |
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Table 2. Tendon and joint US findings at baseline regarding individual and tendon/joint-level evaluation |
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Tendon US findings according to individual-level n=146 |
Tendon US findings according to tendon-level n= 2628 |
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All tendons included in maximum score – n(%) |
All tendons included- n(%) |
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GS=0 |
126 (86.30%) |
GS=0 |
2581 (98.21%) |
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GS=1 |
18 (12.33%) |
GS=1 |
42 (1.60%) |
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GS≥2 |
2 (1.37%) |
GS≥2 |
5 (0.19%) |
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PD=0 |
142 (97.26%) |
PD=0 |
2616 (99.54%) |
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PD=1 |
2 (1.37%) |
PD=1 |
10 (0.38%) |
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PD=2 |
2 (1.37%) |
PD=2 |
2 (0.08%) |
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Joint US findings according to individual-level n=146 |
Joint US findings according to joint-level n= 7008 |
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All joints included in maximum score – n(%) |
All joints included- n(%) |
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GS=0 |
8 (5.48%) |
GS=0 |
6111 (87.20%) |
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GS=1 |
39 (26.71%) |
GS=1 |
535 (7.63%) |
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GS≥2 |
99 (67.81%) |
GS≥2 |
362 (5.17%) |
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PD=0 |
128 (87.67%) |
PD=0 |
6972 (99.49%) |
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PD=1 |
11 (7.53%) |
PD=1 |
20 (0.29%) |
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PD=2 |
7 (4.79%) |
PD=2 |
16 (0.23%) |
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ERO=0 |
138 (94.52%) |
ERO=0 |
6996 (99.83%) |
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ERO=1 |
8 (5.48%) |
ERO=1 |
12 (0.17%) |
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MTPs excluded from maximum score- n(%) |
MTPs excluded- n(%) |
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GS=0 |
31 (21.23%) |
GS=0 |
5036 (90.77%) |
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GS=1 |
71 (48.63%) |
GS=1 |
398 (7.17%) |
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GS≥2 |
44 (30.14%) |
GS≥2 |
114 (2.05%) |
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PD=0 |
132 (90.41%) |
PD=0 |
5519 (99.48%) |
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PD=1 |
8 (5.48%) |
PD=1 |
14 (0.25%) |
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PD=2 |
6 (4.11%) |
PD=2 |
15 (0.27%) |
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ERO=0 |
140 (95.89%) |
ERO=0 |
5540 (99.86%) |
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ERO=1 |
6 (4.11%) |
ERO=1 |
8 (0.14%) |
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US: ultrasound; GS: gray-scale; PD: power-doppler; ERO: erosions; MTP: metatarsophalangeal joints. Assessed joints: shoulders, intercarpal joints, ulnocarpal joint, radiocarpal joint/wrist, elbow, metacarpophalangeal, proximal interphalangeal, knee, ankle, midfoot and metatarsophalangeal joints |
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To cite this abstract in AMA style:
Eugénio G, Mankia K, Pentony P, Nam JL, Hunt L, Gul H, Wakefield RJ, Emery P. First Description of Tenosynovitis Prevalence in a Large Cohort of ACPA-Positive Patients [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/first-description-of-tenosynovitis-prevalence-in-a-large-cohort-of-acpa-positive-patients/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/first-description-of-tenosynovitis-prevalence-in-a-large-cohort-of-acpa-positive-patients/