Ultrasound-guided treatment strategy shows no benefit in early RA
ATLANTA — Data from a 2-year, randomized controlled trial presented here demonstrate that using ultrasound findings to guide early rheumatoid arthritis treatment strategy did not reduce MRI inflammation or result in less structural damage.
“Two trials have recently investigated the use of structured ultrasound assessment in a treat-to-target drug escalation strategy in early RA: the current ARCTIC trial and the TaSER trial,” Espen A. Haavardsholm, MD, PhD, study author and rheumatologist at Diakonhjemmet Hospital, Oslo, Norway, said during a press conference. “Although a beneficial effect of targeting ultrasound remission over clinical remission could not be established in the primary outcome of either of the studies, a trend was observed toward less radiographic erosive damage in the ultrasound arm in both trials.”
Haavardsholm and colleagues examined whether targeting imaging remission, assessed by ultrasound, would improve treatment outcomes. Previously, the ARCTIC trial by Haavardsholm et al, and the TaSER trial by Dale et al, did not show a benefit of adding structured ultrasound assessment to a treat-to-target strategy, but they did demonstrate a trend toward less radiographic progression with ultrasound.
The trial included 230 DMARD-naive patients with early RA from the ARCTIC trial. Patients were aged between 18 and 75 years and were randomized 1:1 to an ultrasound-guided strategy with a Disease Activity Score (DAS) target of < 1.6 with no swollen joints or power-Doppler signals in any joints (n = 116), or a conventional strategy with a DAS target of < 1.6 and no swollen joints (n = 102).
All patients received DMARD escalation, which began with methotrexate, then combination methotrexate/sulfasalazine/hydroxychloroquine, then a biologic DMARD. In the ultrasound group, DAS or swollen joint count results were overruled if the ultrasound score indicated that treatment be stepped up.
Patients underwent MRI of their dominant hand six times and the scans were scored chronologically by a blinded reviewer according to the OMERACT RA MRI Scoring System. Those with MRI at baseline and at least one follow-up were included. Haavardsholm and colleagues computed a combined inflammation score using normalized summation of the synovitis, tenosynovitis and bone marrow edema scores. They calculated a combined damage score by normalized summation of the erosion and joint space narrowing scores.
Findings demonstrated no statistically significant baseline differences between the two groups in either of the combined MRI scores, according to the researchers. During the first year, the mean combined MRI inflammation score decreased by –64.2 in the ultrasound group and by –59.4 in the conventional group; these scores were maintained throughout year 2. There was no significant difference in mean combined MRI damage score between the two groups, though there was a small increase over time. Erosive progression occurred among 39% of patients in the ultrasound group and 33% of those in the conventional strategy group.
“Our findings support that systematic use of ultrasound does not provide benefit in the follow-up of patients with early RA,” Haavardsholm said. – by Stacey L. Adams
Sundin U, et al. Abstract #280. Presented at ACR/ARP Annual Meeting, Nov. 8-13, 2019; Atlanta.
Disclosure: Haavardsholm reports no relevant financial disclosures.