Rheumatology News

Vol. 4 • No. 1 • 2016

The Leading Independent Newspaper from Elsevier

Ultrasound could help identify patients suitable for biologic tapering


MRI findings beyond sacroiliitis not necessary for classifying nonradiographic axial SpA 3

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. 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. 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

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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.

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