“Imaging can frequently change diagnosis and management,” Dr. Emery said. “And personally, I think management of inflammatory arthritis in the 21st century shouldn’t be without imaging.”
In some cases, a single MRI can leave no doubt that a patient has rheumatoid arthritis, and the image can show a level of disease that makes it clear that methotrexate monotherapy will result in further erosion, Dr. Emery said.
Imaging can determine that what is apparently monoarthritis is actually polyarthritis, or even RA, he said. And in RA patients, when true erosions—erosions along with synovitis—are found on ultrasound, it can mean the difference between someone being diagnosed with undifferentiated inflammatory arthritis and a diagnosis of RA. Imaging can also be predictive: The level of synovitis seen on Power Doppler can predict the likelihood of future erosions.2
Use It to Gauge the Level of Disease
When imaging is used to gauge the level of disease, it can help clinicians tailor their dosing levels, Dr. Emery said.
“What we do with rheumatoid arthritis therapy is incredibly crude,” Dr. Emery said. “We give the same dose of targeted therapy to patients when they have very active disease as we do when they are in remission.” But the dose could be titrated according to disease load if imaging were used for guidance, he said.
Dr. Emery said that if a clinician is trying to predict disease course, imaging is necessary and that it’s helpful in gauging initial response and loss of response to treatment, he said.
Imaging should certainly be done in the 30% to 50% of cases in which there is doubt about diagnosis. But Dr. Emery said he is inclined to go further than that. “I would suggest it’s worth imaging most patients just so you know where you are in terms of baseline disease load,” he said, “certainly if you’re going to give aggressive therapy.”
Georg Schett, MD, professor and chair of rheumatology and immunology at the University of Erlangen-Nuremberg, Erlangen, Germany, discussed how imaging and other techniques might be used to identify patients who might stay in remission when biologic therapy is reduced or discontinued.
An interim analysis of results from an RA study out of his center—called the RETRO study—found that about half of the patients maintained remission after therapy was tapered or stopped. A DAS28 of lower than 2.6 was needed for inclusion.3
“Tapering and discontinuation may be a feasible option in some of our patients in daily clinical practice,” Dr. Schett said.
