ROME (FRONTLINE MEDICAL NEWS) – Ultrasound identification of subclinical synovitis allowed clinicians to get the upper hand on early joint damage in rheumatoid arthritis patients who were in remission.

When these patients increased their methotrexate for 52 weeks, follow-up imaging showed that burgeoning joint damage had arrested, Dr. Tadashi Okano said at the annual meeting of the European League Against Rheumatism. The findings suggest that even patients in clinical remission can have subclinically active disease, which can be identified and effectively managed.

“Although the latest recommendations for the treatment of rheumatoid arthritis focus on the achievement of clinical remission, we have demonstrated that patients with subclinical synovitis…should be treated more intensively to reduce the risk of further joint destruction, even when the patient is currently symptom free,” said Dr. Okano of the Osaka City University Graduate School of Medicine, Japan.

Dr. Okano investigated the potential benefit of intensifying treatment for patients who, although in remission, had ultrasound-diagnosed synovitis. The study comprised 134 patients; most (101) had subclinical synovitis as graded by the power Doppler ultrasound score (PDUS). They were randomized to either maintain their methotrexate dosage or to an increased dosage, for 52 weeks. The 33 patients without synovitis served as a control group. Standard radiographs of hands and feet were obtained at baseline, and weeks 24 and 52. Radiological joint damage was assessed according to the modified total Sharp score (mTSS).

By 52 weeks, the total PDUS had decreased significantly more in the intensified methotrexate group than in the stable methotrexate group (–3.9 vs. –2.0 points). Synovitis progression as graded by the mTSS was significantly suppressed in the intensified treatment group as well, both at week 24 (0.27 vs. 1.02) and week 52 (1.03 vs. 2.02).

The improvement was even more pronounced in the subset of 16 patients who were also taking biologics, Dr. Okano said. Joint damage in these patients was suppressed to the point where they resembled patients free of synovitis, with mTSS scores of 0.75 and 0.80, respectively.

“Subclinical active synovitis should be controlled by additional treatment, as this results in the prevention of the joint damage progression, Dr. Okano noted. High-resolution ultrasound offers the chance to identify these patients for early, aggressive management.

Dr. Okano had no financial disclosures.

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