Study compares ultrasound versus conventional strategies in early rheumatoid arthritis

By Dr. Ananya Mandal, MDNov 11 2019

Researchers have found that using the information form ultrasound technology in the treatment protocol did not affect the outcome of the patients with Rheumatoid Arthritis (RA). The study titled, “Ultrasound versus Conventional Treat-To-Target Strategies in Early Rheumatoid Arthritis: Magnetic Resonance Imaging Outcome Data from a 2-year Randomized Controlled Strategy Trial,” was presented at the 2019 ACR/ARP Annual Meeting.

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According to the researchers from Diakonhjemmet Hospital in Oslo, Norway, rheumatoid arthritis remains one of the commonly encountered arthritic conditions that has an autoimmune basis. The immune system of the body is deranged and it leads to painful swelling and disfiguration of the wrists and small joints of hand and feet. Treatment involves modification of the immune system to prevent joint damage. The condition in itself is incurable.

Inflammation and structural damage to the joints within the body can be detected using MRI technology. The researchers found that when information from ultrasound of the body was used in treatment protocols, no extra benefit was seen. In fact, the conventional method of “treat-to-target strategy” was more effective, the team noted.

The team set out to find if the outcomes of patients with early RA was better by targeting correction or remission in the images or ultrasound images along with clinical betterment of the patients. Treatment targets thus were clinical improvement along with ultrasound improvement in one of their study groups of patients. The other group was treated conventionally and the target of the treatment was clinical improvement.

Espen A. Haavardsholm, MD, PhD a rheumatologist at Diakonhjemmet Hospital, lead author of the study said, “Patients who have been seemingly successfully treated and are free of clinical signs and symptoms of disease may continue to develop permanent structural joint damage. There is a need to find better ways to identify these patients and prevent this development.” Haavardsholm added, “The purpose of this follow-up study was to use MRI, which is reliable, objective and more sensitive than X-ray, to make a secondary assessment of inflammatory activity and structural damage progression in the two study arms. If there really were a difference, we would expect to see it in the MRI results.”

There have been similar trials in the past, notable among which is the ARCTIC trial. In this trial 230 patients with early RA who had not been earlier treated with conventional RA management (using DMARDs or Disease modifying Anti-Rheumatoid arthritis drugs) were included. This new trial used data from the ARCTIC trial participants. These patients were aged between 18 and 75 years.

The participants were divided into two groups equally. One of the groups was to follow ultrasound-guided strategy and the target was a reduction in the DAS or disease activity Score to less than 1.6 and also no clinically seen swelling of the joints and no power-Doppler signal detected in any of the joints. The second group was treated in the same manner but the target of the treatment was DAS of less than 1.6 and no swelling of joints. All patients were treated with methotrexate initially followed by a combination of methotrexate/sulfasalazine/hydroxychloroquine and then a biological DMARD agent.

For the ultrasound group, treatment was escalated if the ultrasound score showed necessity despite the fact that the patients had a desirable DAS and no or reduced swollen joints. At the end of the study there were 116 using ultrasound-guided strategy and 102 using a conventional strategy. Each of these patients underwent six MRI scans on the dominant hand of the patient and the results of inflammation at the joints was also scored and correlated. The scoring of the MRI was done by OMERACT RA MRI Scoring System by an interpreter who did not know which group the patient belonged to.

Results revealed that there was no difference between the two groups in the study in terms of MRI scores. The inflammation noted on MRI scoring system showed an average of 64.2 and 59.4 points reduction over the first year in the ultrasound group and conventional treatment groups respectively. The results remain similar in the second year and following years of follow up for the patients. The progression of erosive changes in the joints was 39 percent among the ultrasound group and 33 percent in the conventional treatment group.

Authors wrote in conclusion, “Incorporating ultrasound information in treatment decisions did not lead to reduced MRI inflammation or less structural damage, compared to a conventional treatment strategy. The findings support that systematic use of ultrasound does not provide benefit in treat-to-target follow-up of patients with early RA.”

Professor Haavardsholm said, “Our findings confirm the main conclusion from the ARCTIC trial that targeting ultrasound remission does not lead to improved results. The main message is that people with RA should be diagnosed and started on treatment early, monitored closely, and treatment should be stepped up aggressively until the target of clinical remission is reached. This strategy has proven very successful. However, going beyond this by aiming to also achieve imaging remission increases treatment cost and effort, but does not significantly further improve the results.” He added in conclusion, “So, the ARCTIC trial does not support inclusion of ultrasound examination as a routine measure to guide treatment in early RA. Ultrasound might be a useful tool in other settings, such as when clinical findings are inconclusive. For patients, this means that if you feel that the medication has worked, your joints feel well and your rheumatologist cannot find any signs of active joint inflammation by physical examination, there is in most cases no need to go through additional imaging exams to determine that your disease is under satisfactory control with your current medication.”