Recommendations for the use of ultrasound in rheumatoid arthritis: literature review and SONAR score experience

Abstract

Ultrasound (US) has become a useful tool in the detection of early disease, differential diagnosis, guidance of treatment decisions and treatment monitoring of rheumatoid arthritis (RA). In 2008, the Swiss Sonography in Arthritis and Rheumatism (SONAR) group was established to promote the use of US in inflammatory arthritis in clinical practice. A scoring system was developed and taught to a large number of Swiss rheumatologists who already contributed to the Swiss Clinical Quality Management (SCQM) database, a national patient register. This paper intends to give a Swiss consensus about best clinical practice recommendations for the use of US in RA on the basis of the current literature knowledge and experience with the Swiss SONAR score. Literature research was performed to collect data on current evidence. The results were discussed among specialists of the Swiss university centres and private practice, following a structured procedure. Musculoskelatal US was found to be very helpful in establishing the diagnosis and monitoring the evolution of RA, and to be a reliable tool if used by experienced examiners. It influences treatment decisions such as continuing, intensifying or stepping down therapy. The definite modalities of integrating US into the diagnosis and monitoring of RA treatments will be defined within a few years. There are, however, strong arguments to use US findings as of today in daily clinical care. Some practical recommendations about the use of US in RA, focusing on the diagnosis and the use of the SONAR score, are proposed.

Ultrasound is not associated with the presence of systemic autoimmunity or symptoms in individuals at risk for rheumatoid arthritis

“…Power Doppler settings, depth and gain were optimised to the lowest achievable pulse repetition frequency (PRF) and maximum gain without perceptual noise artefact as per published guidelines 16. A standardised MSUS examination was performed according to the validated, semiquantitative Swiss Sonography in Arthritis and Rheumatism (SONAR) score 9 17–19. Bilateral wrists, metacarpophalangeal and interphalangeal joints 2–5, olecranon fossa, and suprapatellar recess were assessed.…”

“…Synovitis in B-mode and hyperaemia with power Doppler were graded in each joint in line with the Outcome Measures in Rheumatology clinical trials definitions 16 20. Significant level of inflammatory activity on articular MSUS or ‘active MSUS’ was defined as a total B-mode score of greater than 8, including at least one joint with significant synovitis (defined as grade 2 or 3) or significant synovial hyperaemia (defined as Doppler score greater than 1), as previously published 9 21…”

“…Among the various imaging techniques, subclinical MRI inflammation was shown to precede clinical arthritis by a few months 8. Musculoskeletal ultrasound (MSUS) has gained a prominent role in RA management, given technical improvements and accessibility in daily clinical practice 9. In established RA, MSUS is more sensitive than clinical assessment for the detection of synovitis 10.…”

Ultrasound can be useful to predict an evolution towards rheumatoid arthritis in patients with inflammatory polyarthralgia without anticitrullinated antibodies

“…We and others have reported on US synovitis scoring systems (SONAR score) that is able to detect in both B and Doppler modes clinically meaningful synovitis when applied among controls and RA patients and able to detects clinical relevant changes in RA patients [11]. This score has also been shown to be reproducible among rheumatologists who have followed a complete training course [12].…”

Scores échographiques : intérêt en pratique rhumatologique (exemple de la polyarthrite rhumatoïde et des spondyloarthrites)

“…Parmi les 16 scores retenus (Tableaux 1-3), 7 d'entre eux ne comportaient pas de données psychométriques publiées, comme pour la reproductibilité inter et intra-observateur [17][18][19][20][21][22][23]. Le score de Hartung était basé sur l'évaluation des grosses articulations (épaules, genoux, coudes, hanches), ne correspondant pas aux articulations de référence de la PR.…”