Terslev Lene, Brahe Cecilie Heegaard, Østergaard Mikkel, Fana Viktoria, Ammitzbøll-Danielsen Mads, Møller Torsten, Krabbe Simon, Hetland Merete Lund, Døhn Uffe Møller
Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark.
Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Arthritis Res Ther. 2021 Feb 1;23(1):48. doi: 10.1186/s13075-021-02426-w.
Subclinical synovitis by ultrasound is a frequent finding in rheumatoid arthritis (RA) patients in remission and has been shown to be related to erosive progression, risk of flare and unsuccessful drug tapering, but it has not been investigated how a DAS28 T2T-steered strategy in routine care affects the presence of subclinical synovitis in RA patients in remission. The aim of the current study was to investigate the presence of ultrasound-detected subclinical inflammation in RA patients in long-term remission receiving either biological or conventional disease-modifying anti-rheumatic drugs (bDMARD/csDMARD) and, finally, to investigate the presence of ultrasound remission using different ultrasound remission criteria.
Eighty-seven RA patients (42 patients receiving bDMARD and 45 csDMARD) received DAS28-CRP-steered treatment in routine care and had achieved DAS28-CRP-remission for > 1 year without radiographic progression. Twenty-four joints were scored 0-3 by ultrasound (elbows, wrists, knees, ankles, metacarpophalangeal and metatarsophalangeal joints 2-5) for grey-scale synovial hypertrophy (GS) and colour Doppler activity (CD) using the OMERACT scoring system. Ultrasound remission was defined as strict (GS score = 0 and CD score = 0), semi-strict (GS score < 1 and Doppler score = 0) and Doppler remission (Doppler score = 0).
No differences between treatment groups were found for GS sum score and Doppler sum score (median (range) 6 (0-19) and 0 (0-12), respectively). A Doppler score > 0 in at least 1 joint was seen in 44%, a GS score > 1 in at least 1 joint in 93% and a GS score > 2 in at least 1 joint in 54% of patients. Strict ultrasound remission was only observed in bDMARD patients (7%; p = 0.01). Thirty-seven per cent were in semi-strict ultrasound remission and 56% in Doppler remission (no significant difference between groups) with similar results across the subgroups of patients who also fulfilled the ACR-EULAR Boolean-, CDAI- and SDAI-remission criteria.
Ultrasound frequently detected subclinical synovitis in RA patients in longstanding DAS28-remission obtained through a DAS28-CRP-steered strategy. This was independent of treatment and applied ultrasound remission criteria. Strict ultrasound remission was rare.
超声检查发现的亚临床滑膜炎在缓解期类风湿关节炎（RA）患者中很常见，且已被证明与侵蚀性进展、病情复发风险及减药失败有关，但尚未研究在常规治疗中采用DAS28治疗达标（T2T）策略如何影响缓解期RA患者亚临床滑膜炎的存在情况。本研究的目的是调查接受生物或传统改善病情抗风湿药物（bDMARD/csDMARD）治疗的长期缓解期RA患者中超声检测到的亚临床炎症的存在情况，最后使用不同的超声缓解标准调查超声缓解的情况。
87例RA患者（42例接受bDMARD治疗，45例接受csDMARD治疗）在常规治疗中接受基于DAS28-CRP的治疗，且已实现DAS28-CRP缓解超过1年且无影像学进展。使用OMERACT评分系统对24个关节（肘部、腕部、膝部、踝部、第2 - 5掌指关节和跖趾关节）进行超声评分（0 - 3分），以评估灰阶滑膜肥厚（GS）和彩色多普勒活动（CD）情况。超声缓解定义为严格缓解（GS评分 = 0且CD评分 = 0）、半严格缓解（GS评分 < 1且多普勒评分 = 0）和多普勒缓解（多普勒评分 = 0）。
治疗组之间在GS总分和多普勒总分上未发现差异（中位数（范围）分别为6（0 - 19）和0（0 - 12））。44%的患者至少有1个关节的多普勒评分 > 0，93%的患者至少有1个关节的GS评分 > 1，54%的患者至少有1个关节的GS评分 > 2。仅在接受bDMARD治疗的患者中观察到严格超声缓解（7%；p = 0.01）。37%的患者处于半严格超声缓解，56%的患者处于多普勒缓解（组间无显著差异），在同时满足美国风湿病学会（ACR）-欧洲抗风湿病联盟（EULAR）布尔值、临床疾病活动指数（CDAI）和简化疾病活动指数（SDAI）缓解标准的患者亚组中结果相似。
在通过基于DAS28-CRP的策略实现长期DAS28缓解的RA患者中，超声经常检测到亚临床滑膜炎。这与治疗及应用的超声缓解标准无关。严格的超声缓解很少见。
