MRI findings beyond
sacroiliitis not necessary
for classifying
nonradiographic
axial SpA
3
Etanercept during
pregnancy doubles
the odds of major
malformations
4
Wearable device offers
home-based knee OA
pain relief
6
Potential etanercept
response biomarker
identified
9
End-stage renal
disease risk in lupus
nephritis remains
unchanged of late
11
Fibromyalgia found in 20%
with spondyloarthritis;
could affect
management decisions
12
The pain of inflammatory
disease goes beyond
the physical
15
IN THIS ISSUE
Ultrasound could help identify patients
suitable for biologic tapering
BY NICOLA GARRETT
Frontline Medical News
From Arthritis Research & Therapy
U
ltrasound evaluation at the time of clinical re-
mission could be a useful tool to select the most
appropriate rheumatoid arthritis (RA) patients
to undergo biologic therapy tapering and discontinu-
ation, Italian researchers say.
In a study involving 42 RA patients in clinical
remission who tapered their anti-tumour necrosis
factor-alpha (anti-TNF-alpha) therapy according
to ultrasound criteria, 69.1% maintained remission
at 12 weeks.
Furthermore, 26 of the patients (89.7%) main-
tained disease remission after 6 months of follow-
up, reported the research team led by Dr Gianfranco
Ferraccioli and Dr StefanoAlivernini of the Institute
of Rheumatology, Catholic University of the Sacred
Heart, Rome (
Arthritis Res Ther
2016. doi: 10.1186/
s13075-016-0927-z).
The 30% of patients who relapsed (n=13) were re-
treated and reached a good European LeagueAgainst
Rheumatism (EULAR) response within 3 months,
results from the observational study showed.
According to the researchers, the daily manage-
ment of patients receiving long-term biologic treat-
ment remains a matter of debate, and it is currently
unclear how to select the most appropriate patients
for discontinuing biologic treatment.
People with RA, even when in remission, tend to
have residual synovitis. Previous research had shown
that patients with negative signalling detected on
power Doppler (PD) ultrasound were less likely to
have disease flares.
To determine if the detection of residual synovitis
with PD signalling could help in selecting patients
suitable for anti-TNF discontinuation, the research-
ers selected 42 RA patients with disease duration
of more than 12 months who were in sustained
remission (Disease Activity Score less than 1.6 at
three visits 3 months apart) who were receiving anti-
TNF-alpha treatment plus methotrexate.
Patients were first tapered on anti-TNF-alpha
therapy (adalimumab 40 mg/4 weeks or etanercept
50 mg/2 weeks).
Each patient underwent ultrasound evaluation of
synovial hypertrophy (SH) and PD signal presence
in the second and third metacarpophalangeal (MCP)
and proximal interphalangeal (PIP) joints, the wrist
(radiocarpal-intercarpal), bilateral knee, and second
to fifth metatarsophalangeal (MTP) joints.
After 3 months, patients with no power Doppler
signalling on ultrasound discontinued anti-TNF-
alpha therapy and were followed every 3 months
while maintaining stable doses of methotrexate.
Disease flares after anti-TNF-alpha discontinu-
ation occurred in the joints with higher SH scores
that were clinically involved at disease onset, despite
the fact that no SH cut-off discriminated patients
who relapsed from those who did not.
In particular, the fifth MTP joint was informative
(in both the tapering and discontinuation groups)
and the second MCP joint was informative for the
tapering group only.
“This finding suggests the possible utility of fol-
lowing US [ultrasound] with indices of joints ini-
tially involved at disease onset with higher likelihood
of relapse,” the researchers said.
Results from subgroup of five patients who also
underwent ultrasound-guided knee synovial tissue
biopsy to assess histologic features of residual syno-
vitis revealed that the absence of ultrasound activity
was associated with almost normal findings at the
synovial level, they reported.
Overall, the findings suggested there was a “mean-
ingful, large patient population with established RA
in remission for whom the anti-TNF-alpha dose
can be decreased without clinical and functional
worsening,” the researchers wrote.
They suggested the combination of PD-US evalua-
tion andAmerican College of Rheumatology/EULAR
remission criteria could help identify patients on bio-
logics who are likely to achieve drug-free remission.
Use of three sequential ultrasound evaluations
might identify an even higher proportion of patients
likely to reach persistent drug-free remission, com-
pared with current clinical methods of disease activ-
ity assessment, they added.
Gianfranco Ferraccioli declared receiving consulting
fees and speaking fees from Wyeth, Roche, AbbVie,
and Bristol-Myers Squibb. The other authors said that
they have no competing interests.
The findings suggested there was a
meaningful, large patient population with
established RA in remission for whom the
anti-TNF-alpha dose can be decreased
without clinical and functional worsening.
The Leading Independent Newspaper from Elsevier
Vol. 4 • No. 1 • 2016