Background/Purpose

Patients (pts) with rheumatoid arthritis (RA), who achieve clinical disease remission by treatment with disease- modifying agents may have residual joint inflammation and vascularization, which can be detected by Power Doppler (PD) ultrasonography. The aim of this analysis was to evaluate the proportion of RA pts with PD activity, 24 weeks (wks) after the addition of adalimumab (ADA) to methotrexate (MTX).

Methods

MUSICA (NCT01185288), a 24 wk double-blind, randomized, controlled trial evaluated the efficacy of 2 different dosages of MTX (7.5 or 20 mg/wk) plus ADA (40 mg every other wk) in RA pts with inadequate response to MTX. For this analysis, the MTX dosage groups were combined. Synovial vascularization was assessed by PD US at 10 joints (bilateral dorsal and volar views of metacarpophalangeal joints 2, 3, 5; dorsal images alone of metatarsophalangeal joint 5 and wrists), at baseline (BL), wks  4, 8, 12, 16, 20 and 24. Images were scored by ultrasound-experienced rheumatologists using a semi-quantitative 4-grade scale.Joint swelling was assessed for the same 10 joints (SJC10). Disease activity was assessed by 28-joint count disease activity score using C-reactive protein (DAS28[CRP]) (remission < 2.6, LDA < 3.2, MDA 3.2- < 5.1, HDA ≥ 5.1), and simplified disease activity index (SDAI) (remission ≤3.3, LDA ≤11, MDA 11-≤26, HDA >26). Pearson’s coefficient (ρ ) was used to assess correlation between continuous variables.

Results

After 24 weeks of treatment with ADA +MTX, 44/309 pts (14%) were in DAS28 (CRP) remission (mean PD score, 3.3); 18/309 (5.8%) pts were in SDAI remission (mean PD score, 2.7).  23/44 pts (52%) in DAS28 remission, and 9/18 (50%) in SDAI remission had a PD score ≥ 2, indicating inflammatory activity. At wk 24, for the 10 joints selected, 30/44 (68%) pts in DAS28(CRP) remission had positive PD scores, while only 15 pts (34%) had ≥ 1 swollen joint,  and only 5 pts (13.6%) had ≥ 1 tender joint. Ten out of 18 (55%) pts in SDAI remission had a positive PD score, while none had swollen/tender joints. A poor correlation (ρ<0.2) was observed between PD scores and clinical disease scores such as DAS28, SJC66, SJC28, TJC68, TJC28, CDAI, SDAI, PhGA, PGA-pain and disease duration. There was poor correlation (ρ=0.184) between the change from BL to wk 24 in PD scores, and the change from BL to wk 24 in DAS28(CRP) or SDAI.  The corresponding shifts in disease activity, mean PD score and SJC10 scores are presented (Table).

Table 1. Mean changes in PD score, DAS28(CRP) score and SJC10 from BL to wk 24
DAS disease state shift (BL→wk 24)	N	Mean change in PD score	Mean change in DAS28(CRP) score	Mean change in SJC10
MDA→MDA	24	-0.5	-0.6	-1.1
MDA→LDA	29	-0.8	-2.2	-2.4
HDA→HDA	41	-1.0	-0.6	-1.3
HDA→MDA	94	-1.8	-2.0	-2.7
HDA→LDA	57	-2.3	-3.6	-4.3
Mean changes in PD score, SDAI score and SJC10 from BL to wk 24
SDAI Disease state shift (BL→wk 24)	N	Mean change in PD score	Mean change in SDAI score	Mean change in SJC10
MDA→MDA	9	-0.7	-7.1	0.2
MDA→LDA	15	-0.4	-15.0	-1.9
HDA→HDA	55	-1.1	-12.6	-1.1
HDA→MDA	85	-1.9	-26.4	-2.7
HDA→LDA	81	-1.9	-35.9	-4.1
PD, power Doppler; DAS28(CRP), disease activity state 28 using c-reactive protein; SJC10, swollen joint count (10 joints); SDAI, simplified disease activity index; LDA, low disease activity; MDA, moderate disease activity; HDA, high disease activity

Conclusion In agreement with other studies, residual joint inflammation was detected by PD US in pts in clinical remission; therefore ultrasound can offer additional information to that obtained from clinical disease measures.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-use-of-ultrasound-to-detect-residual-joint-inflammation-in-patients-with-rheumatoid-arthritis-in-clinical-disease-remission/