Ultrasound-Guided Treat-to-Target in RA

Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission   pdf

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The absence of specific guidance on how to use ultrasound (US) to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of US in clinical practice, potentially limiting its benefits for patient outcomes. In view of th…

Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial   pdf

Percentage attainment of response criteria after 18 months follow-up:

Median Health Assessment Questionnaire (HAQ). (†p=0.31, ††p=0.06):

Objective To investigate whether an intensive early rheumatoid arthritis (RA) treat-to-target (T2T) strategy could be improved through the use of musculoskeletal ultrasound (MSUS) assessment of disease activity. Methods 111 newly diagnosed patients with RA or undifferentiated arthritis (symptom dura…

Ultrasound guidance of early RA therapy doesn’t improve outcomes

SNOWMASS, COLO. – Ultrasound does not seem to have an advantage over clinical evaluation in helping to guide treat-to-target strategy in early rheumatoid…

Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial   pdf

Objective  To determine whether a treatment strategy based on structured ultrasound assessment would lead to improved outcomes in rheumatoid arthritis, compared with a conventional strategy. Design  Multicentre, open label, two arm, parallel group, randomised controlled strategy trial. Setting  Ten…

ARCTIC Study Shows No Benefit to Ultrasound Remission in RA

The goal in rheumatoid arthritis (RA) treatment is remission. But what level or method of remission is best? Using clinical parameters, there are numerous definitions of remission to choose from (ACR boolean, CDAI, SDAI, etc.) and not all measures perform equally when applied to the same patients.

Systemic ultrasound in the management of early rheumatoid arthritis is not justified

LONDON — The systemic use of ultrasound in…

Is it time to revisit the role of ultrasound in rheumatoid arthritis management?   pdf

For over a decade, a large number of studies have highlighted the benefits of ultrasound (US) in the diagnosis and management of rheumatic diseases,…

Ultrasound, especially power Doppler (PDUS), has demonstrated its usefulness in the entire range of RA management, from early diagnosis, to monitoring, to tapering, and to flare. The only controversial link in this chain is in guiding treatment intensity to achieve disease remission. That’s owing to 2 recently published landmark trials: TaSER and ARCTIC.
On cursory reading (especially if all you read are the abstracts’ conclusions), then you’ll conclude that using ultrasound to guide therapy results in higher costs (more man-hours spent scanning the joints; higher usage of costly biologics) without a commensurate or better remission rate compared to current standard-of-care (which uses clinical outcome measures to guide therapy).
To be fair, current standard-of-care is really very good. Because of tight disease activity control, we as rheumatologists no longer see RA patients with joint deformities commonly shown in textbooks. Therefore, for ultrasound to better that is a tall order to begin with.
However, if you read the detailed results in the 2 studies, you’ll find that ultrasound-guided (USG) treat-to-target (T2T) yielded numerically superior scores in remission rates as well as clinical outcome measures like disease activity scores, albeit the differences were not statistically significant (with the exception of DAS44 remission at 18 months in TaSER). Interestingly, when you look at patient reported outcomes (PRO) like function and quality of life, USG-T2T (HAQ in TaSER) showed a trend towards superiority by 18 months, which was almost statistically significant. And in ARCTIC, USG-T2T appeared to significantly retard radiographic progression (joint damage) after 2 years in the roughly 15% of patients with more severe disease (called the “rapid progressors”).
The interpretation of these results continues to be hotly debated among rheumatologists. I think the following points complicate the interpretation:
1) As mentioned earlier, the comparator is active tight control, which is very effective in achieving clinical remission as is;
2) USG-T2T is driven mainly by PDUS, and the current semi-quantitative grading system (0-3) is not clear on what grade constitutes clinically significant inflammation deserving of treatment escalation (grade 1 or 2?), and inter-rater reliability remains weak between grades 2 & 3;
3) To define a primary remission endpoint in terms of the comparator’s targeting strategy is problematic, it’s like using a yardstick to measure the yardstick. Are the current clinical remission criteria (EULAR Boolean, DAS28/44, SDAI, etc) or even the radiographic outcome (modified Sharp score) the ultimate target? I posit that PROs are more clinically meaningful and therefore ultimately more relevant and important. I made reference to this in my earlier “MRI in RA” post, and shall be elaborating on it in a later post on “PRO in RA”.
Given my perspective, my take-home on TaSER and ARCTIC are:
1) Imaging (PDUS & MRI) allows for targeting a deeper remission than clinical outcome measures;
2) A deeper remission which is sustained is needed to improve PRO, which is a more important target than clinical remission;
3) USG-T2T is unnecessary for every RA patient at every review, especially if the patient reports to be doing well enough (not keen for therapeutic adjustments), even if the physician global assessment is in discordance. Instead, it should be reserved for monitoring the small proportion of rapid progressors.