Clinicians should consider escalating therapy in patients with early rheumatoid arthritis who have persistent foot synovitis regardless of disease activity status, Australian rheumatologists have suggested.

The advice comes after the team of doctors from several hospitals in Adelaide, South Australia, found that patients who were in remission according to disease activity (DA) standard measures but had foot synovitis were almost twice as likely to relapse, compared with patients in remission without foot synovitis.

These patients also were more likely to have worse long-term radiographic and functional outcomes, Dr. Mihir D. Wechalekar of Flinders University, Adelaide, and his colleagues reported (Arthritis Care Res. 2016. doi: 10.1002/acr.22887 ).

The research team assessed the disease activity in 266 patients attending the Early Arthritis Clinic at Royal Adelaide Hospital using the Disease Activity Score 28 (DAS28), clinical disease activity index (CDAI), and the simplified disease activity index (SDAI).

Patients also received yearly hand and foot radiographs and their quality of life was measured via the Medical Outcome Study Short–Form 36 (SF-36) questionnaire.

Patients were treated initially with triple-DMARD therapy and were escalated to achieve DAS28(ESR) remission by increasing methotrexate or adding a further DMARD or biologic DMARD according to a predefined treatment algorithm.

The researchers discovered that DA scores captured less than 50% of the variation in foot swollen joint count/tender joint count scores, “indicating that assessment of disease activity using these criteria is likely to be insufficient for detecting disease flares in the feet.”

Furthermore, the authors noted that despite the SDAI and CDAI being considered “more stringent” remission criteria, 24% of patients in SDAI remission and 25% of patients in CDAI remission had ongoing foot synovitis.

The sustainability of remission influenced the progression of erosion scores (P = .006); foot synovitis was linked to worse SF-36 physical functioning (P = 0.025).

“Our findings emphasize the importance of examining the ankle and foot as a part of the routine management of patients with RA,” the research team concluded.

“Given the impact of foot synovitis on stability of remission, radiological progression, and independent impact on quality of life, decisions should not be made solely on the basis of DA scores that omit foot joints,” they wrote.

“Presence of foot synovitis despite apparent remission should prompt escalation of therapy to prevent long-term joint damage and improve functional outcomes,” they added.