Rheumatoid arthritis

Fresh research fires up debate on ultrasound in RA


New research out of Norway suggests the systematic use of Doppler ultrasound (DUS) in the management of patients with early rheumatoid arthritis is not justified.

However both Australian and UK experts say DUS still has an important role in the treatment and management of RA patients, and have their own evidence to back this up.

The latest study, published in the British Medical Journal details results of the randomised controlled strategy trial carried out at 10 rheumatology departments and one specialist centre in Norway, from September 2010 to September 2015.

The ARCTIC (Aiming for Remission in rheumatoid arthritis: a randomised trial examining the benefit of ultrasound in a Clinical TIght Control regimen) study compared two tight control treatment strategies for early RA to assess whether incorporation of ultrasound information into treatment decisions, as well as targeting therapy towards imaging remission, would lead to improvement in a combined outcome of sustained clinical remission, absence of swollen joints, and inhibition of joint damage.

The researchers said the study highlighted the importance of conducting randomised controlled trials to evaluate not only drugs but also new technologies or new treatment strategies, but concluded the implementation and systematic use of ultrasound in the follow-up of patients with early rheumatoid arthritis treated with an aggressive tight control strategy “is not justified on basis of the results of the ARCTIC trial”.

“And the result should be reflected in future recommendations and guidelines for managing patients with rheumatoid arthritis,” they wrote.

“Ultrasound may have an important role in the diagnosis of rheumatoid arthritis and in procedures such as intra-articular injections. Future studies should focus on the potential benefit of ultrasound in these areas, as well as the possible role of ultrasound in evaluating disease activity and tailoring treatment in patients with established rheumatoid arthritis.”

Former EULAR president and highly respected UK rheumatologist, Professor Paul Emery, was quick to reply in a rapid response letter published by the BMJ.

Prof Paul Emery is the Arthritis Research UK Professor of Rheumatology and Director of the Leeds Institute of Rheumatic and Musculoskeletal Medicine and the Director of the Leeds Musculoskeletal Biomedical Research Unit at Leeds Teaching Hospitals Trust, UK.

He used the BMJ letter to congratulate the authors on their study of ultrasound (US) in rheumatoid arthritis, and the “extraordinary attention to therapeutic detail, with great efficacy in both arms, and under the circumstances of this study US examination did not improve outcomes.”

However such a high level of attention may not always be replicated in clinical practice.

“The most important finding from ARCTIC is that rheumatoid arthritis treated with exceptional care (in one of the wealthiest countries which can afford such intensive therapy) very low levels of PD for the first time can be achieved; with “most patients in both groups having no Power Doppler”,” they wrote.

“However, to conclude “isolated sub-clinical inflammation, in the absence of clinically detectable disease has minimal clinical importance” is not possible from the data in this paper.”

Australian researcher and rheumatologist, Professor Fred Joshua said the research showed that treating to ultrasound can’t be justified in early stage disease, but this did not mean DUS did not have a role to play in the management of patients with RA.

About two months ago, Professor Joshua told the limbic he believed DUS played an important part in helping clinicians to monitor disease progression.

As leader of the study, Defining Rheumatoid Arthritis Progression using Doppler Ultrasound in Clinical Practice (DEDUCE), which set out to assess the current use of DUS in Australian patients with RA, he said rheumatologists’ interest in the use of DUS was growing steadily.

It had also turned out to be a boon in improving RA patients’ attitudes towards treatment adherence. Nearly all patients who underwent DUS assessment (94%) in the study saying that discussing DUS with their rheumatologist helped them take medications according to their rheumatologists’ directions.

“It’s very exciting to see the interest in upskilling and training, it has really picked up in the last three years,” he told the limbic then. “I think it’s also really good to show the community that we’re not just playing at it.”

Speaking to the limbic this week, Professor Joshua said he stood by his previous comments. He welcomed the BMJ research, which served to highlight the fact that DUS was not for every patient and physicians should not be “blindly following it as a protocol.”

“Ultrasound is not to be used at the exclusion of all other diagnostic tools,” he said. “It’s showing that we have to be careful about how we use the technology.”

He said there was little doubt DUS was helpful for patients with active disease but minimal symptoms, and in encouraging medication compliance.

He said red flags for using DUS to monitor RA patients includes:

  • High blood markers
  • Clinical uncertainty relating to joint swelling
  • Whether the use of DUS will change the diagnosis and enhance communication between patients and doctors

“I think we need to be rational in our use of all technology,” he said.

 

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