Ultrasound unnecessary in treatment of early RA patients
Using ultrasound as a treatment strategy does not benefit treat-to-target follow-up of patients with early rheumatoid arthritis (RA), researchers from Norway stated in a scientific presentation at the 2019 annual meeting of the American College of Rheumatology (ACR/ARP) held in November in Atlanta. Incorporating ultrasound data in treatment decisions did not lead to reduced magnetic resonance imaging (MRI) inflammation or less structural damage compared to a conventional treatment strategy, they reported.
Researchers at Diakonhjemmet Hospital in Oslo sought to determine whether treatment outcomes in early RA can be improved by assessing imaging remission with ultrasound in addition to assessing clinical remission. They said primary analyses of two clinical trials, ARCTIC and TASER, did not show that adding structured ultrasound assessment to a treat-to-target strategy was beneficial to early RA patients. However, results from both studies showed a trend toward less radiographic progression in the ultrasound arms.
ARCTIC is a randomized clinical trial conducted to determine if treatment based on structured ultrasound assessment would improve patient outcomes compared to a conventional treatment. TaSER is a randomized clinical trial conducted in the United Kingdom investigating if an intensive early RA treat-to-target strategy could be improved through musculoskeletal assessment of disease activity.
“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, said senior author and rheumatologist Espen A. Haavardsholm, MD, PhD. “If there really were a difference, we would expect to see it in the MRI results.”
The trial used data from the ARCTIC trial, including that of 230 DMARD-naïve patients aged 18 to 75 with early RA. Patients were randomized to follow either an ultrasound-guided strategy targeting DAS (Disease Activity Score) of less than 1.6 with no swollen joints and no power-Doppler signal in any joint, or a conventional strategy targeting DAS of less than 1.6 and no swollen joints.
Treatment of all patients began with methotrexate, then escalated to combination therapy with methotrexate/sulfasalazine/hydroxychloroquine, then a biologic disease-modifying anti-rheumatic drug. In the ultrasound group, patients stepped up their treatment if the ultrasound score indicated a need, overruling the DAS or swollen joint count results.
MRI was performed six times on patients’ dominant hand, then scored in chronological order by a blinded reader, according to the OMERACT RA MRI Scoring System. One hundred sixteen patients using the ultrasound-guided strategy and 102 using a conventional strategy had an MRI at the study’s baseline and one or more follow-up visits.
The study showed no statistically significant baseline differences between the two treatment groups in either of the combined MRI scores. The scores were maintained at the same level throughout the second year of follow-up.
There was no significant difference in change from baseline between the two groups at any time. The mean combined MRI damage score showed a small increase over time, without any significant difference between the two groups. In the ultrasound group, 39% of patients had MRI erosive progression compared to 33% in the conventional strategy group.
“Our findings confirm the main conclusion from the ARCTIC trial that targeting ultrasound remission does not lead to improved results,” said Dr. Haavardsholm. “The findings of the ARCTIC trial that we conducted do not support inclusion of ultrasound examination as a routine measure to guide treatment in early RA.”
REFERENCES
- Haavardsholm EA, Aga AB, Olsen IC, et al. Ultrasound in management of rhematoid arthritis: ARCTIC randomised controlled strategy trial. BMJ. 2016;354:i4205. doi: 10.1136/bmj.i4205.
- Dale J, Stirling A, Zhang R, et al. Targeting ultrasound remission in early rhematoid arthritis: the results of the TaSER study, a randomized clinical trial. Ann Rheum Dis. 2016;75(6):1043-50. doi:10.1136/annrheumdis-2015-208941.