基线PD超声预测经TNFBA治疗获临床缓解RA病人未来发生放射学损害

原文

译文

OP0029

USEFULNESS OF POWER DOPPLER TO PREDICT RADIOLOGICAL DAMAGE IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION BY TNF BLOCKERS

B. Raffeiner ^{1, 2,*}, P. Sfriso ¹, M. Gutierrez ³, V. Ravagnani ⁴, G. Carpenito ⁵, C. Botsios ¹, L. Bernardi ¹, F. Ometto ¹, L. Punzi ¹

¹Rheumatology Unit, University of Padova, Padova, ²Rheumatology Unit, Internal Medicine Hospital Bolzano, Bolzano, ³Rheumatology Unit, University of Ancona, Ancona, ⁴Rheumatology, Sanitary District Carlo Poma, Mantova, ⁵Rheumatology, Hospital of Mirandola, Modena, Italy

Background: Functional outcome of patients with rheumatoid arthritis (RA) depends from control of disease activity and arrest of radiological damage. Remission of clinical activity can nowadays be achieved in the majority of RA patients by combinations of glucocorticoids, synthetic DMARDs and TNFα blockers. Recent imaging studies identified subclinical inflammation in many patients in treatment with synthetic DMARDs considered in clinical remission. Active synovitis was demonstrated by MRI and ultrasound. Power Doppler (PD) positivity correlated best with radiological progression despite clinical remission induced by synthetic DMARDs (1). TNFα blockers are much more efficacious in blocking radiological damage by direct inhibition of osteoclasts. It is not known if PD positivity predicts on-going damage also in RA patients in remission by TNFα blockers.

Objectives: To determine usefulness of PD study to predict structural damage in patients considered in clinical remission by TNFα blocker therapy.

Methods: Prospective observational study was performed on 109 consecutive RA patients in therapy with TNFα blockers. Patients in DAS28 remission since 6 months were considered. At baseline after clinical and laboratory evaluation confirming clinical remission, ultrasound examination was performed in all patients on the metacarpophalangeal, proximal interphalangeal, wrist and metatarsophalangeal joints with Logiq 5 (GE, 12 MHz linear probe, PD 5 MHz, PRF 0,9 kPa). Active synovitis was identified by PD positivity. Semi-quantitative scoring 0-3 as defined for PD and number of joints presenting PD positivity were registered. At baseline and after one year X-rays of hands and feet were executed. Radiological progression was expressed as difference in total Sharp Score modified by van der Heijde (∆TSS) > 0. Correlations between PD positivity and radiological progression were analyzed by the test of Spearman.

Results: Of 109 patients 54 (49,54%) showed no PD signal at the time of remission, whereas 55 (50,46%) had PD signal: 31 grade 1, 15 grade 2 and 9 grade 3. 36 patients showed PD positivity in one joint, 19 in more joints. All patients without PD signal did not show radiological progression. In 29,1% of patients with PD positivity radiological progression occurred. This corresponded to 14,68% of all patients in clinical remission analyzed. Radiological progression did not correlate with number of joints presenting PD, but correlated well with PD scoring grades (p<0,001). 22,6% of patients with grade 1, 40% with grade 2 and 50% with grade 3 suffered from radiological progression.

Conclusions: PD demonstrated to be very useful in evaluating patients considered to be in remission. Absence of PD signal guarantees arrest of radiological progression, whereas patients with PD signal are at risk for radiological progression despite treatment with TNFα blockers. This risk increases with higher PD grades.

References: Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, Hensor E, Wakefield RJ, O’Connor PJ, Emery P. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum 2008;58(10):2958-67.

基线PD超声预测经TNFBA治疗获临床缓解RA病人未来发生放射学损害

B. Raffeiner . EULAR 2011. Present No: OP0029

背景: 类风湿性关节炎(RA)患者的功能预后取决于疾病活动的控制和放射学破坏的阻断。目前大多数的类风湿关节炎患者在糖皮质激素、合成DMARDs和TNFα拮抗剂联合治疗下能获得临床缓解。最近的影像学研究发现合成DMARDs治疗下被认为临床缓解的患者仍有亚临床炎症。MRI和超声能证实活动性滑膜炎。不论DMARD是否已经诱导临床缓解，能量多普勒(PD)的阳性发现与放射学进展相关性最佳(1)。TNFα阻滞剂通过直接抑制破骨细胞能更有效地抑制放射学破坏。对于TNFα拮抗剂诱导缓解的RA患者，其PD阳性发现是否能预测持续的破坏尚不得知。

目的: 为明确TNFα拮抗剂诱导临床缓解的RA患者中， PD检测对于预测结构破坏的作用。

方法:对109例持续接受TNFα拮抗剂治疗的RA进行前瞻性观察研究。6个月以后DAS28缓解的患者纳入本研究。基线时经过临床和实验室评估后确认临床缓解的，对所有患者进行超声检查，部位包括掌指、近端指间、腕和跖趾关节，参数为Logiq 5(GE、12MHz线性探针、PD 5MHz,PRF 0,9 kPa)。PD能发现阳性的活动性滑膜炎。记录PD半定量积分0 – 3和阳性关节数。分别摄取基线及一年后的手足x线片。放射学进展以van der Heijde改良的总Sharp评分差异(∆TSS)> 0表示。PD阳性与放射学进展的相关性应用Spearman方法检测。

结果: 109例患者中有54例(49.54%)在缓解时没有PD阳性表现，,而55例(50.46%)有PD信号:31例为1级,15例2级,9例3级。36例患者为单关节PD阳性,19例表现为多个关节。所有无PD信号的患者并没有表现出放射学的进展。PD阳性的患者中有29.1%的病人出现放射进展。因而所有临床缓解的患者中有14.68%患者进行了分析。放射学进展与PD阳性的关节数不相关,但与PD积分的等级呈良好相关性(p < 0.001)。22.6%的1级患者、 40%的2级患者和50%的3级患者发生了放射学进展。

结论:PD被证实在评价患者的缓解状态非常有价值。PD的阴性结果确保了放射学进展的停滞,而PD阳性信号的患者不论是否用TNFα拮抗剂治疗则仍然有放射学进展的风险。这种风险随着PD分级增高而升高。 .