Background/Purpose:

To determine remission in RA, recent publications point out the importance of radiological parameters, besides scores like DAS28, TJC, SJC, CrP, patient global assessment, or the SDAI. ⁽¹⁾ Inflammatory activity can remain despite clinical remission in RA.⁽²⁾ This process can be monitored with modern imaging without radiation exposure – high-field MRI and colour and power Doppler sonography. These diagnostic methods are also valuable for the determination of an OFF therapy or an individual dose adaption.⁽³⁾The latest adaptions allow the precise monitoring of cartilage and subchondral bone under cytokine therapy in clinical practice.

The course of chronic active inflammation at affected joint structures can be quantitatively and qualitatively measured by aforementioned techniques. The aim is to optimize and control biologic therapy.

Methods:

22 RA-patients (12 men, 10 women, between 20 and 72 years of age) with high disease activity at baseline (DAS 28 over 3.3, CRP over 10, ESR over 20, fibrinogen over 470 mg/dl, RF positive, high erosion tendency (anti-CCP positive)) were treated 8mg TCZ/kg body weight  from 08/2008 until now, data were analyzed retrospectively. 3 female patients from each group received TCZ (iv q4w) in combination with MTX, while all other patients received TCZ in monotherapy.

Examination criteria at baseline and before infusion administration were DAS 28, serum fibrinogen, colour and power Doppler ultrasound examination, and every 3 to 6 months high-field MRI (T1 T2 STIR KM 3.0 T; panorama image) of the affected joints’ inflammation activity, the cartilage, or the subchondral bone. The evaluation was carried out using MRI (RAMRIS) and sonography score. 

Results:

Of the 22 patients observed 10 patients (6 men, 4 women) exhibited early or very early RA (group A); 5 patients (1 man, 4 women) established RA with low articular cartilage destruction and erosion (Sharp score of up to 2; group B); and 7 patients (3 men, 4 women) chronically established RA (Sharp Score 3; group C) at baseline.

After 12 week, all inflammation parameters, including DAS 28, were within the normal range. Inflammation activities could still be detected by Doppler ultrasound imaging and MRI. Cartilage imaging showed no erosions and changes in the subchondral bone in group A during the course of the therapy. In group B, the cartilage and bone erosion also stopped. In group C, the cartilage or subchondral bone destruction progressed, despite the decrease of inflammation parameters. 

Conclusion:

The cytokine therapy with tocilizumab leads to a rapid decrease in the inflammation parameters and hence to a normalization of DAS 28. The inflammation-verifying imaging such as the aforementioned Doppler sonography and the high-field MRI still registered inflammation activities during the course of the therapy. The use of TCZ as mono therapy for early and very early RA extensively decreases the inflammation process and prevents cartilage/bone destruction. In chronically established, advanced RA (Sharp score 3), the systemic inflammation can be inhibited, while the cartilage and subchondral bone destructions remained progressive during the course of the disease.

---

« Back to 2012 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/synovialitis-plus-articular-cartilage-monitoring-via-magnetic-resonance-imaging-and-ultrasound-under-tocilizumab-therapy-in-patients-with-rheumatoid-arthritis/