Division of Rheumatology, McGill University.
Canadian Rheumatology Ultrasonography Society (CRUS).
Rheumatology (Oxford). 2020 Oct 1;59(10):2746-2753. doi: 10.1093/rheumatology/keaa004.
Since the creation of the Canadian Rheumatology Ultrasonography Society, an increasing number of rheumatologists has been trained in the use of musculoskeletal US (MSUS). We compared the effectiveness of MSUS to routine care (RC) as a disease management tool in patients with moderate-to-severe RA requiring a treatment change due to lack of efficacy. The predictive value of MSUS was also assessed.
This was a prospective, two-cohort, quasi-experimental study. Patients were managed either with MSUS (within the Canadian Rheumatology Ultrasonography Society) or as per RC for up to 1 year. Main outcomes included Clinical Disease Activity Index low disease activity/remission, DAS28 low disease activity/remission, MSUS scores, patient satisfaction and perception of participation in disease management.
A total of 383 patients were enrolled (MSUS: n = 171; RC: n = 212). At baseline, a greater proportion of MSUS patients were treated with a biologic DMARD (50.3 vs 36.8%; P = 0.008) while more patients treated per RC received a non-biologic DMARD (84.2 vs 91.5%; P = 0.027). During follow-up, a greater number of RA treatment modifications was applied in the MSUS group compared with RC [adjusted incidence rate ratio (95% CI): 1.4 (1.1, 1.8)], including steroids, non-biologic DMARDs and biologic DMARDs. Regarding clinical and patient-reported outcomes, no remarkable differences were observed between groups. However, throughout the study, 50-80% of MSUS patients in clinical remission has a MSUS synovitis score of ≥1, and 37-73% an erosion score of ≥1. Significant associations were observed between baseline synovitis and joint erosion during follow-up.
MSUS assessments can be useful in detecting subclinical levels of inflammation and predicting future joint deterioration, thus allowing optimization of RA treatment and patient care.
自加拿大风湿病超声学会成立以来，越来越多的风湿病学家接受了肌肉骨骼超声（MSUS）的使用培训。我们比较了 MSUS 作为一种疾病管理工具在因疗效不佳而需要改变治疗的中重度 RA 患者中的效果，以及 MSUS 的预测价值。
这是一项前瞻性、两队列、准实验研究。患者接受 MSUS 治疗（在加拿大风湿病超声学会内）或常规护理（RC），治疗时间最长为 1 年。主要结局包括临床疾病活动指数（DAS28）低疾病活动/缓解、MSUS 评分、患者满意度和对疾病管理参与的感知。
共纳入 383 例患者（MSUS：n=171；RC：n=212）。基线时，MSUS 组接受生物 DMARD 治疗的患者比例（50.3% vs 36.8%；P=0.008）更高，而接受 RC 治疗的患者中接受非生物 DMARD 治疗的患者比例（84.2% vs 91.5%；P=0.027）更高。随访期间，MSUS 组比 RC 组进行了更多的 RA 治疗调整[调整后发病率比（95%CI）：1.4（1.1，1.8）]，包括皮质类固醇、非生物 DMARD 和生物 DMARD。在临床和患者报告的结局方面，两组之间没有显著差异。然而，在整个研究过程中，50-80%处于临床缓解期的 MSUS 患者的 MSUS 滑膜炎评分≥1，37-73%的患者的侵蚀评分≥1。在随访期间观察到基线滑膜炎和关节侵蚀之间存在显著关联。
MSUS 评估可用于检测亚临床炎症水平，并预测未来的关节恶化，从而优化 RA 治疗和患者护理。
