Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments.

Saleem B, Brown AK, Keen H, Nizam S, Freeston J, Wakefield R, Karim Z, Quinn M, Hensor E, Conaghan PG, Emery P.

1Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds Teaching Hospital NHS Trust, Chapel Allerton Hospital, Leeds, UK.

Abstract

OBJECTIVES: /st> Patients can fulfil clinical criteria for remission, yet still have evidence of synovitis detectable clinically and by ultrasound, and this is associated with structural damage. Stricter remission criteria may more accurately reflect true remission (no synovitis). This hypothesis was examined by studying patients using more stringent thresholds for clinical remission and determining their levels of ultrasound synovitis.

METHODS: /st> Rheumatoid arthritis patients with a disease activity score in 28 joints (DAS28) ≤2.6 for at least 6 months were classified using standard and more stringent DAS28 and simplified disease activity index (SDAI) remission thresholds and the corresponding clinical and ultrasound imaging measures of synovitis recorded.

RESULTS: /st> 128 patients (all DAS28 <2.6, median DAS28 1.70) receiving either disease-modifying antirheumatic drugs alone (n=66) or with a tumour necrosis factor blocker (n=62) were recruited. Of the 640 imaged joints, 5% had moderate or severe power Doppler (PD) activity, 8% were clinically swollen and 1% tender. In patients fulfilling DAS28, American College of Rheumatology or SDAI remission criteria, moderate or severe PD activity was present in 21%, 15% and 19%, respectively. More stringent DAS28 and SDAI criteria reduced the mean number of swollen and tender joints (p<0.001) but not the percentage of patients with PD activity: 32 patients had a DAS28 <1.17 but eight (25%) had significant PD activity.

CONCLUSION: /st> Using more stringent remission criteria resulted in reduced signs and symptoms of inflammation, but the percentage of joints with PD activity was not reduced, even in those without signs or symptoms. These data suggest that clinical criteria are sufficiently insensitive to detect low but clinically relevant levels of inflammation accurately.

影像学是否应该纳入RA缓解标准？传统评分与修订后复合评分和影像学评估的比较

Saleem B, et al.Ann Rheum Dis. 2011 Jan 17.

目的：符合临床缓解标准的患者仍可能存在临床上和超声上的滑膜炎，其与结构破坏相关。更严格的缓解标准可能可以更为准确地反映真正的缓解（没有滑膜炎）。本文在研究患者中采用更加严格的临床缓解阈值，检测超声上滑膜炎程度。

方法：DAS28≤2.6超过6个月的RA患者根据标准和更严格的DAS28、简化疾病活动度积分（SDAI）缓解阈值进行分类，记录相关的临床上和超声上滑膜炎情况。

结果：128例患者（DAS28 <2.6，平均DAS28 1.70）单用DMARDs（n=66）或联用TNF抑制剂（n=62）。在640个成像关节中，5%有中至重度能量多普勒（PD）活动度，8%临床肿胀，1%压痛。在达到DAS、ACR、SDAI缓解标准的患者中，分别有21%、15%、19%出现中至重度PD活动度。更严格的DAS28标准和SDAI标准可减少平均肿胀关节数和压痛关节数（p<0.001），但不能降低PD活动患者比例：32例患者DAS28 <1.17，但8例（25%）PD显著活动。

结论：更严格的缓解标准能减少炎症的症状和体征，但不能降低PD活动关节比例，即使是在没有症状和体征的关节。这些数据提示临床标准不能敏感检测出有临床意义的低炎症水平。