Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds Teaching Hospital NHS Trust, Chapel Allerton Hospital, Leeds, UK.
Ann Rheum Dis. 2011 May;70(5):792-8. doi: 10.1136/ard.2010.134445. Epub 2011 Jan 17.
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.
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.
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.
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.
患者可能符合缓解的临床标准，但仍存在临床上和超声检查可检测到的滑膜炎证据，这与结构损伤有关。更严格的缓解标准可能更准确地反映真正的缓解（无滑膜炎）。通过研究使用更严格的临床缓解标准的患者并确定其超声滑膜炎水平，检验了这一假说。
至少 6 个月疾病活动评分 28 个关节（DAS28）≤2.6 的类风湿关节炎患者，使用标准和更严格的 DAS28 和简化疾病活动指数（SDAI）缓解标准进行分类，并记录相应的临床和超声滑膜炎检查结果。
共招募了 128 例（所有 DAS28<2.6，中位 DAS28 为 1.70）接受单独疾病修饰抗风湿药物（n=66）或肿瘤坏死因子阻滞剂（n=62）治疗的患者。在 640 个成像关节中，5%有中度或重度功率多普勒（PD）活动，8%有临床肿胀，1%有压痛。在符合 DAS28、美国风湿病学会或 SDAI 缓解标准的患者中，中度或重度 PD 活动分别占 21%、15%和 19%。更严格的 DAS28 和 SDAI 标准减少了肿胀和压痛关节的平均数量（p<0.001），但没有减少 PD 活动患者的比例：32 例患者的 DAS28<1.17，但 8 例（25%）有明显的 PD 活动。
使用更严格的缓解标准可减少炎症的体征和症状，但 PD 活动关节的百分比并未降低，即使在没有体征或症状的患者中也是如此。这些数据表明，临床标准对检测低但临床相关水平的炎症不够敏感。
