Background/Purpose:

We have previously reported that patients with subclinical synovitis defined by synovial hypertrophy grade >2 (SH>2) plus power Doppler (PD) signal had  higher disease activity, higher levels of serum inflammatory/angiogenic biomarkers [Ramírez J, Arthritis Research and Therapy 2014 Jan 8;16(1):R5] and less were on corticosteroid treatment. The aims of this study were to validate this ultrasound criteria for subclinical synovitis (SH>2+PD) in a different cohort of patients with chronic inflammatory polyarthritis in clinical remission on anti-TNF therapy.

Methods:

Patients diagnosed with RA or polyarticular PsA in clinical remission (DAS28-ESR<2.6) on anti-TNF therapy were included. Ultrasound scans of both hands were performed in all patients, with scoring of Synovial hypertrophy (SH) (grades 0-3) and power Doppler (PD) (grades 0-3). Angiogenic and proinflammatory cytokines were determined by Multiplex ELISA in patients with RA and PsA in remission and compared with the levels of two control cohorts: 22 active RA patients (DAS28>3.2) and 20 healthy controls.

Results:

We included 77 patients [47 PsA and 30 RA, mean age (standard deviation, SD) 57.3 (11.5) years, disease duration 15.7 (8.3) years, DAS28 1.85 (0.41), time of remission 4.2 (3.3) years] of whom 42 were on etanercept, 25 adalimumab and 10 on infliximab. Forty (51.9%) patients were on monotherapy and 38 (49.3%) were receiving tapered doses of TNF antagonists.

Globally, 31 patients had PD signal and 12 had SH>2 plus PD, meeting the criteria of ultrasound-defined subclinical synovitis. Despite no clinical differences were found, patients with criteria of sonographic subclinical synovitis had significantly higher levels of IL-6, IL-20, PIGF and SDF1.

Interestingly, the serum biomarker profile in PsA in remission was similar to the healthy control, whereas serum biomarker profile in RA in remission was more similar to that of active RA patients.

11 out of 30 RA patients in clinical remission (p=0.0001) versus only 1 PsA patient met criteria for sonographic subclinical synovitis. In line with these findings, significantly more PsA patients were receiving tapered dose of biologics (63.8%), and more frequently as monotherapy (72.3%), compared with RA patients in clinical remission (26.6% and 20%, respectively).

Conclusion:

We have shown that sonographic criteria for subclinical synovitis in patients with chronic inflammatory polyarthritis in remission are useful to identify patients with higher burden of local and systemic inflammation. It remains to be demonstrated if patients meeting that criteria have a higher rate of joint flare and radiographic progression.  Finally, our findings suggest that clinical remission under anti-TNF therapy is qualitatively better in PsA than in RA.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/validation-of-a-new-ultrasound-criteria-for-subclinical-synovitis-in-chronic-inflammatory-polyarthritis/