IS THERE A DISSOCIATION BETWEEN CLINICAL REMISSION AND ULTRASONOGRAPHIC ASSESSMENT IN RHEUMATOID ARTHRITIS?

Background: Achieving remission is the aim of treatment in RA. Modern joint imaging improves the accuracy of remission measurement in RA; In particular Power Doppler Ultrasonographic (PDUS) findings may have a predictive value in disease activity and radiologic outcome.Objectives: To Evaluate and to confirm the clinical remission and the absence of synovial inflammation by means PDUS monitoring.Rheumatology Unit of Modena was the promoter of the URAR study (Ultrasound evaluation in RA patients with clinical remission) national group that aims to this target.Methods: The patients were recruited in the Rheumatology Unit of Modena and they were chosen sequentially in the rheumatologic out-patient's department dedicated to arthritis.The study included 54 patients (10 men, 44 women) with RA in therapy with DMARDS, anti-TNF or no therapy in clinical remission according to ACR criteria and DAS 28 < 2.6. All patients had active wrist or hand inflammation in the past. US examination evaluated the presence of active Synovitis (ACD), Power Doppler (PD) signal and Sinovial Hypertrophy (SH) on the following bilateral joints: Metacarpophalangeal – Proximal Interphalangeal joints – Flexor tendons (on 2°-3° fingers) and Wrist (radiocarpal and midcarpal joints). Scores and scales have been chosen according to the literature (1)Results: 19 patients (35.2%) displayed a negative US evaluation in the meaning of an agreement between clinical and US parameters. However 35 patients (64,1%) with clinical remission showed a positive ultrasonographic assessment and at least an active parameter (ACD, PD, SH). No correlation was found between US examination and antibody assessment (anti-CCP and RF): according to the statistic function "Half-Normal Plot" parameters are completely independent. Small differences were also found between patients in therapy with anti-TNF or other therapies (DMARDS, corticosteroids): they showed similar US assessment so that there is no statistical significance in the comparison between the two groups. Among eleven patients that presented swollen and tender joints at the latest physical examination which preceded US exam just 5 patients had a correspondence at the US: positive joints at the clinical evaluation showed a US confirmation too. Otherwise the other patients had a mismatch between clinical assessment and the PDUS: it did not confirm the presence of inflammation in the corresponding swollen – tender joints or showed a positive ultrasonographic assessment in other locations.Conclusion: The remission state is a great therapy target and its attainment seems to be possible and not only through the biological therapy.Clinical remission is not always confirmed by US evaluation, therefore it is not possible to exclude a complete absence of synovial inflammation just on the base of DAS 28 value. It seems particularly interesting the mismatch between clinical assessment and PDUS: according to this finding an integration between clinical and US results seems to be useful to guide clinical procedure and disease monitoring.