The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study

Filippou, Georgios; Sakellariou, Garifallia; Scirè, Carlo Alberto; Carrara, Greta; Rumi, Federica; Bellis, Emanuela De; Adinolfi, Antonella; Batticciotto, Alberto; Bortoluzzi, Alessandra; Cagnotto, Giovanni; Caprioli, Marta; Canzoni, Marco; Cavatorta, Francesco Paolo; Lucia, Orazio De; Sabatino, V. Di; Draghessi, Antonella; Farina, Ilaria; Focherini, M. C.; Gabba, Alessandra; Gutiérrez, Marwin; Idolazzi, Luca; Luccioli, Filippo; Macchioni, Pierluigi; Massarotti, Marco; Mastaglio, Claudio; Menza, Luana; Muratore, Maurizio; Parisi, Simone; Picerno, Valentina; Piga, Matteo; Ramonda, Roberta; Raffeiner, Bernd; Rossi, Daniela; Rossi, Silvia; Rossini, P; Scioscia, Crescenzio; Venditti, Carlo; Volpe, Alessandro; Iagnocco, Annamaria

doi:10.1136/annrheumdis-2018-213217

Cited by 79 publications

(52 citation statements)

References 36 publications

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“…US examination as a sensitive imaging technique for the detection of synovitis may be needed to determine imaging remission [39][40][41]. This is important as US-detected synovitis in clinical remission is a predictor for a relapse and loss of remission [9,10,42].…”

Section: Discussionmentioning

confidence: 99%

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Musculoskeletal ultrasound as a biomarker of remission – results from a one-year prospective study in patients with rheumatoid arthritis

2018

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Aims: To assess the role of musculoskeletal ultrasound (MSUS) as a biomarker of remission and to compare the rates of clinical and imaging remission in patients with rheumatoid arthritis (RA) on different types of treatment.Material and methods: One hundred and forty-one patients underwent physical and ultrasound examination at 5 visits (at baseline and after 1, 3, 6 and 12 months). Patients were divided into two groups according to the type of treatment, which involved synthetic (sDMARDs) and biologic (bDMARDs) disease-modifying antirheumatic drugs. Ultrasound assessment of the wrist, second and third metacarpophalangeal, second and third proximal interphalangeal joints, and the second and fifth metatarsophalangeal joints was performed on gray scale ultrasound (GSUS) and on power Doppler ultrasound (PDUS) (German US7-score). The rate of imaging and clinical remission (DAS28, SDAI, CDAI, and Boolean) was established. The percentage of patients in clinical remission with persistent PD signal was assessed.Results: In the sDMARDs group at month twelve, 43.6% of the patients achieved DAS28 remission, 5.1% – SDAI, 3.8% – CDAI, and 3.8% – Boolean remission. In the bDMARDs group 49.2% achieved DAS28 remission, 6.3% – SDAI, 4.8% – CDAI, and 4.8% – Boolean remission. Irrespective of which clinical index was applied, all patients in clinical remission had persistent synovial hypertrophy on GSUS. Synovial PD signal (PDUS score≥1) was detected in 77% and 71% of patients in DAS28 remission in the sDMARDs and bDMARDs group, respectively. Patients in SDAI, CDAI and Boolean remission in both treatment groups did not have а positive PD signal.Conclusions: There is persistence of synovitis both in patients on sDMARDs and bDMARDs in DAS28 clinical remission. This fact points to a discordance between DAS28 clinical remission and the imaging remission assessed by MSUS irrespective of the type of treatment. MSUS may be a feasible imaging method for the assessment of residual inflammation in daily rheumatology practice.

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Section: Discussionmentioning

confidence: 99%

“…MSUS has been proved to be more sensitive than physical examination for the detection of synovitis [7]. Evidence exists that the presence of a power Doppler (PD) signal in RA patients in clinical remission predicts structural progression and a recent relapse [4,[8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Musculoskeletal ultrasound as a biomarker of remission – results from a one-year prospective study in patients with rheumatoid arthritis

2018

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“…On one hand, the lack of ultrasound activity predicts achievement and persistence of remission (33,34). On the other hand, there is a very high degree of confidence that residual synovial activity is a significant predictor for loss of remission (relapse, flare) and radiographic progression since controlled studies (35)(36)(37), meta-analyses (38,39), magnetic resonance imaging (MRI) studies (40)(41)(42)(43)(44)(45)(46), biological markers (14) and histology (47,48) have confirmed the cited ultrasound observations. The loss of remission tends to happen in the first year of follow-up (39), especially if treatment is withdrawn (49,50).…”

Section: Introductionmentioning

confidence: 71%

Clinical and ultrasound ankle involvement in rheumatoid arthritis in remission

Enache¹,

Popescu²,

Codreanu³

et al. 2019

Ro J Rheumatol.

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Objective. We aimed to evaluate the prevalence and differences of clinical and ultrasound involvement of ankles in rheumatoid arthritis (RA) patients in remission. Methods. RA patients were recruited in 2018 in the random order of presentation from the outpatient clinic. In the day of enrolment, all patients underwent clinical examination (by a senior rheumatologist, blind to other evaluations), inflammatory markers (e.g. C-reactive protein-CRP) and ankle ultrasound (performed and interpreted by a single rheumatologist with more than 7 years of experience). Results. The sample included 59 patients in DAS28CRP remission, 27 in SDAI remission and 20 in Boolean remission. Among these 3 categories of remission, overall clinical ankle involvement presented similar prevalence (revolving around 30%). On average, 77% of patients presented overall ultrasound ankle involvement among the 3 categories of remission, with similar frequencies of ankle joint synovial hypertrophy (SH; 33%), power Doppler (PD) positive joint SH (15%), ankle joint effusion (60%), ankle tenosynovitis (27%) and PD positive ankle tenosynovitis (15%). In the subgroup of RA patients in DAS28CRP remission, compared to patients without clinical or ultrasound ankle involvement, those with at least one involved ankle had a significantly higher median CRP (0.34 mg/dl versus 0.19 mg/dl, p = 0.042). Conclusion. Among RA patients in remission, regardless of its definition, clinical and ultrasound involvement of ankles is frequent. Clinical and ultrasound screening of ankles in RA patients in remission seems an appropriate strategy.

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“…Another study in RA patients with active disease and US-verified tenosynovitis reported that patient's VAS for tenosynovitis pain was responsive to treatment, parallel to improvement in US parameters, indicating that patients' pain perception may be triggered by tenosynovitis alone [34]. There is growing evidence that imaging-detected tenosynovitis has impact on RA diagnosing and prognostication of radiographic outcomes and prediction of clinical flares [35][36][37][38]. Our findings add to this evidence and lend support to the importance of tenosynovitis assessment at flares.…”

Section: Discussionmentioning

confidence: 99%

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

et al. 2020

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Background: Magnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA. Methods: Eighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements. Results: Synovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05). Conclusions: Patient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.

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The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study

Abstract: PD positivity in tendons and joints is an independent risk factor of flare in patients with RA in clinical remission. Musculoskeletal ultrasound evaluation is a valuable tool to monitor and help decision making in patients with RA in clinical remission.

Cited by 79 publications

References 36 publications

Musculoskeletal ultrasound as a biomarker of remission – results from a one-year prospective study in patients with rheumatoid arthritis

Musculoskeletal ultrasound as a biomarker of remission – results from a one-year prospective study in patients with rheumatoid arthritis

Clinical and ultrasound ankle involvement in rheumatoid arthritis in remission

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

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