Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.


Application of Ultrasound to Treat to Target Management of Rheumatoid Arthritis - Multicentre International Observational Experience.

Aydin1,  Sibel, Buch2,  Maya H., Horton3,  Sarah, Ikeda4,  Kei, Iagnocco5,  Annamaria, Gutierrez6,  Marwin, Grassi7,  Walter

Goztepe Training and Research Hospital, Istanbul, Turkey
The Parker Institute, Copenhagen, Denmark
Charite University Hospital, Berlin, Germany
Versailles-Saint Quentin en Yvelines University- APHP, Ambroise-Paré Hospital, Boulogne-Billancourt, France
Leeds Institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals, Leeds, United Kingdom
Leeds Institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK, Leeds, United Kingdom
Leeds institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Disease Biomedical Research Unit, Leeds Teaching Hospitals, Leeds, United Kingdom
Leeds institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Disease Biomedical Research Unit, Leeds Teaching Hospitals, United Kingdom
Chiba University Hospital, Chiba, Japan
Uni, Jesi, Italy
Sapienza Universita di Roma, Rome, Italy
Università Politecnica delle Marche, Jesi, Italy
Hosptial Universitario Severo Ochoa, Madrid, Spain
La Paz University Hospital, Madrid, Spain

Background/Purpose:

The recent formulation of 'treat to target' (T2T) recommendations on the management of rheumatoid arthritis (RA) (1) aim to improve patient outcomes. We aimed to investigate the additional role of ultrasound (US) to T2T clinical assessment.

Methods:

An audit of 9 centres (8 countries) where musculoskeletal US is part of routine patient care was undertaken. Patients with active RA, requiring additional treatment and follow-up according to T2T recommendations were included. Clinical and US data were collected. US data from MCP 2–3, radiocarpal, intercarpal, MTP 5 joints and extensor carpi ulnaris tendon (where available) were analysed.

Results:

At time of analysis, 93 patients had been audited. Baseline mean (SEM) characteristics included: Age 52.6 (15.5), disease duration 7.8 (11) years, DAS28 score 4.9 (1.5) and HAQ 2.4 (2.8). 78% were RF and 69%, ACPA positive. Thirty-five patients were on no DMARDS at baseline. At baseline, 81 % of patients had at least one joint PD signal.

The pre-defined disease activity target was achieved in 25% and 49% of patients at 3 and 6 months respectively. Therapy was modified in only 16–44 % of active patients; the main reason reported as "waiting for the previous treatment escalation to work" (13–76%) (Table 1).

At month 3, 50% of cases still had PD signal (38% PD>=2) in at least one joint despite achieving clinical target. Fifty percent of cases with clinical activity and PD signal did not receive any therapy modifications. Similarly at month 6, 53% of patients achieving clinical target still had PD signal in at least one joint with 20 % with PD>=2. Twenty-eight percent of patients received no treatment modification despite clinical disease activity and PD presence (Table 2).

Table 1. Summary of clinical assessments in each visit

CLINICAL ASSESSMENTMonth 1M2M3M4M5M6
n745955484349
DAS283.83.53.43.13.13.2
HAQ2.51.210.90.91
Clinical target achieved n (%)11 (15)17 (29)14 (25)22 (46)17 (40)24 (49)
Modification (in active group)28/63 (44)17/42 (40)17/41 (42)4/25 (16)10/26 (39)10/25 (40)
Type of modification      
  Dose increase25/2810/178/172/44/101/10
  Add DMARDS1/282/174/172/43/107/10
  Biologics2/282/175/170/41/102/10
Additional steroids (n/active group)4/636/424/412/253/262/25
Reason for no modification: Previous treatment to work n (%)25/33 (76)13/25 (52)14/23 (61)14/21 (67)2/16 (13)8/15 (53)

Table 2. PD findings according to clinical assessment at month 3 and 6.

Clinical target for disease activity Any PD signalPD>=2
nposnegposneg 
At month 3 (n=41)     
  Achieved84435
  Not-achieved332851914
  Modification1413168
At month 6 (n=28)     
  Achieved1587312
  Not-achieved13112103
  Modification98172

Conclusion:

In this audit, therapy modifications were avoided in more than 50% of eligible RA patients at monthly visits, mainly due to waiting for the effect of previous treatments. A third to half of these cases also had PD signal, which has previously been demonstrated to be an independent risk factor for progression (2). US is a useful adjunct to clinical T2T approach and can inform patients who may particularly benefit from monthly treatment escalation.

Reference:

(1)Smolen, JS et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69:631–7.

(2)Brown, AK et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58:2958–67.

To cite this abstract, please use the following information:
Aydin, Sibel, Buch, Maya H., Horton, Sarah, Ikeda, Kei, Iagnocco, Annamaria, Gutierrez, Marwin, et al; Application of Ultrasound to Treat to Target Management of Rheumatoid Arthritis - Multicentre International Observational Experience. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2144
DOI:

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