Background/Purpose: Several studies have shown the presence of subclinical inflammation by ultrasound (US) in rheumatoid arthritis (RA) patients despite clinical remission according to clinical composite scores. However, no agreement exists on which joints to assess when monitoring RA patients in remission to reveal potential subclinical inflammation. The present objective was to evaluate if US examination of the hands is sufficient for this purpose.

Methods: A total of 209 patients with RA (mean (SD) age 53 (13) years, disease duration 10 (9) years, 81% women, 79% anti-CCP positive) were included when initiating bDMARDs, with 182 patients continuing at 6 months and 152 patients at 12 months. The patients were assessed at baseline and after 6 and 12 months with patient’s global disease activity VAS, clinical examination (assessor’s disease activity VAS, tender and swollen joint counts performed by a study nurse) and ESR. DAS28(ESR), CDAI, SDAI and ACR/EULAR Boolean remission were calculated. All US examinations (semi-quantitative scoring (0-3)) of GS and PD (PIP 2-3, MCP 1-5, wrist (RC, IC, RU), elbow, knee, tibiotalar, MTP 1-5 and extensor carpi ulnaris (ECU)/tibialis posterior (TP) tendons bilaterally) were performed by one rheumatologist (HBH) with high intra-reader reliability (using Siemens Acuson Antares, excellence version, 5-13 MHz probe, optimized for PD with no upgrading during the study). In all the calculations only GS ≥2 and PD≥1 were regarded as US pathology. To explore if bilateral examinations of the hands (wrist, MCP/PIP joints, ECU tendon) could represent overall US pathology, the percentages of patients with US pathology present only in other sites than the hands (i.e. elbow, knee, ankle, MTP joints, TP tendons) at 6 and 12 months were calculated.

Results: At 6 months, depending on the different composite scores, 20.7%-40.8% were in clinical remission, but in these patients, US pathology was commonly present (75.7% – 86.1% for GS and 67.6% – 77.2% for PD). At 12 months, 23.0%-38.8% of the patients were in clinical remission, still having GS and PD pathology in 60.0% – 78.0% and 57.1% – 72.5%, respectively (table 1 shows the percentage US pathology depending on joint regions). In patients in remission, there was a low frequency of patients with US pathology only in joints other than the hands (GS found in 13.2 – 17.1% and PD in 2.4- 8.1 % at 6 months and 12 months) (table 2).

Conclusion: A majority of patients in remission according to clinical composite scores still had US pathology (especially in wrist, finger and MTP joints). PD activity has been shown to be associated to radiologic damage, and presently a very low percentage of patients had PD activity not detected by examination only of the hands. Thus, a feasible US examination including only the hands seems to reveal most of the patients with subclinical inflammation.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/is-ultrasound-of-the-hands-enough-to-reveal-ongoing-subclinical-inflammation-in-rheumatoid-arthritis-patients-in-clinical-remission-according-to-composite-scores/