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ObjectivesOptimal management of rheumatoid arthritis (RA) depends on accurate evaluation of disease activity. Foot synovitis is not included in the most used RA outcome measure (DAS-28 score). The aim of this study was to investigate how musculoskeletal ultrasound (MSK-US) examination of hand and feet correlate with the disease activity score (DAS-28 score). We also explored whether performing MSK-US assessments of hands alone compared with hands and feet underestimates the disease activity in RA.MethodsThis is a real-life cross-sectional study of 101 patients (51 with RA and 50 with other musculoskeletal conditions) with inflammatory small joint pain, who underwent MSK-US examination of hands and feet.ResultsMSK-US-detected hand synovitis was found in 18/51 (35.3%) RA patients and 16/50 (32%) of those with other musculoskeletal conditions (p = 0.96), while foot synovitis was detected in 18/51 (35.3%) and 12/50 (24%) patients, respectively (p = 0.78). DAS-28 did not correlate with any of the US outcome measures in patients with RA. Six out of 13 (46.1%) RA patients in remission, 7/14 (50%) with low disease activity and 18/32 (56.2%) with moderate disease activity (according to DAS-28 definition) had active synovitis as assessed by the MSK-US examination of their hands and feet. MSK-US-detected synovitis led to treatment escalation in 26/51 (51%) RA patients.ConclusionThis study emphasises that MSK-US examination of hands and feet has led to optimised management of the majority of RA patients, which would have not been possible otherwise, because of the lack of correlation between DAS-28 assessment and MSK-US outcomes.Key Points • The most used disease activity score in rheumatoid arthritis (DAS-28) did not correlate with US outcome measures derived from hands and feet examination. • DAS-28 did not differentiate between RA patients with subclinical active synovitis versus well-controlled disease on US. • As a result of US examination of the hands and feet, 51% RA patients had their immunosuppressive treatment optimised. Electronic supplementary materialThe online version of this article (10.1007/s00330-019-06187-8) contains supplementary material, which is available to authorized users.

BackgroundThe Disease Activity Score including 28 joint count (DAS-28) is the most widely used outcome measure in RA. However, despite evidence that metatarsophalangeal (MTP) joints are often the first joints affected in RA, DAS-28 score does not incorporate them.ObjectivesOur study aimed to investigate the correlation between DAS-28 assessment and objective evidence of active joint inflammation using the US examination of both hands and feet, including wrists, metacarpophalangeal (MCP), proximal interphalangeal (PIP), and MTP joints.MethodsA retrospective study was conducted, including 87 patients who were referred to the US clinic for an examination of their hands and feet in the last 6 months (46 patients with RA and 43 controls - patients with other inflammatory or degenerative arthropathies). Information about demographics, disease duration, current treatment, inflammatory markers, and DAS-28 scores was captured. The US OMERACT criteria were used for grading synovial hypertrophy, and assessing for the presence of Power Doppler (PD) signal, erosions and osteophytes. Statistical analysis methods included T-test, Mann-Whitney U test, Z score for proportions and Spearman's correlation coefficients.ResultsIn the RA group, DAS-28 had a weakly positive correlation with the cumulative PD scores of their hands and feet joints (R=0.14, P=0.02), but did not correlate with PD score of MTP joints (R=0.03, P=0.09). In the control group, DAS-28 did not correlate significantly with either the total PD scores of feet (R=0.42, P=0.26) or hands and feet joints (R=0.5, P=0.25). Sensitivity of US examination of hands alone compared to hands and feet was 74.3% for the RA group, while the sensitivity of US feet to detect the presence of PD was 59.2% when compared to the US of both hands and feet.ConclusionsWe found that DAS-28 correlated poorly with objective evidence of inflammation as detected by US of the hands and feet, and this correlation was lost when only the presence of inflammation in the feet was taken into consideration. Further validation of our results in a larger study including patients stratified based on the disease duration might help understand which patient subgroups are more likely to have their disease activity significantly under-evaluated using DAS-28 outcome measure.Disclosure of InterestNone declared

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The most common types of chronic inflammatory arthritis are rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. In order to assess the activity of these diseases and tailor therapy, several outcome measures have been developed. They include composite scores based on clinical findings, biochemical markers and patient questionnaires. This article discusses the most commonly used outcome measures and looks at their limitations in quantifying the complex clinical features of different types of inflammatory arthritis, focusing in particular on rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.