Musculoskeletal Ultrasound Assessment Changes Management Decisions in Rheumatoid Arthritis Patients With Moderate Disease Activity

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BACKGROUND: Musculoskeletal ultrasound (MSUS) provides valuable information about disease activity and anatomical damage in rheumatoid arthritis (RA); therefore, in combination with clinical assessment, it may be a useful tool in clinical decision-making with treatment. OBJECTIVES: (1) To evaluate the impact of MSUS assessment on treatment decisions in patients with moderately active RA receiving conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). (2) To determine the level of concordance between MSUS assessment and DAS28 in these patients. METHODS: RA patients with a DAS-28 ranging from 3.22-5.1, inadequate response to csDMARDs, and indication for escalating treatment were enrolled. All patients underwent an ultrasound (US) examination (B and PD modes) of the bilateral 5-joint count (5USJC), the symptomatic joints of the DAS-28 score (28USJC), and of a comprehensive 78-joint count (78USJC). A Likert scale (pre- and post-MSUS) was used to assess patients' and clinicians' desires to escalate treatment. The outcome of the treatment decision based on US assessment was reviewed at 24 months' follow-up. RESULTS: Among the 27 patients included, the mean (SD) DAS-28 score was 4.4 (0.7). Following US assessment, there was a change in the decision to escalate treatment in 18 patients (66.7%), and at a median follow-up of 24 months, only in 5 of the 18 patients had the treatment had been escalated. Treatment escalation was associated with a higher US score across all assessments (5USJC, 28USJC, 78USJC) (p < 0.05). The 78USJC was the most reliably aligned with the treatment decision (p = 0.009). A comparison of the US and clinical assessment revealed poor concordance between all variables of the DAS-28 and US scores, except for the swollen joint count. CONCLUSION: The addition of MSUS assessment to the DAS-28 score affected management decisions in 66.7% of patients.

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