Ultrasounds for Rheumatoid Arthritis, Part 3
Ultrasounds as sensational tests for RA
Over the last couple of days, we have taken a look at musculoskeletal ultrasound tests for Rheumatoid Arthritis. We explored the value of ultrasounds (MUS) compared to other tests for RA. We have seen that ultrasounds for Rheumatoid Arthritis are more precise and sensitive than x-ray tests for RA. The machines are less expensive and the procedure is less invasive than MRI’s which are of similar value to “see” the damage of Rheumatoid Arthritis.
Problems with obtaining a valid MUS for Rheumatoid Arthritis
Then, we examined some problems with obtaining a valid ultrasound for Rheumatoid Arthritis. MUS is highly dependent upon the expertise of the operator. There is a need for standardization of training, standardization of interpretations of data, and skillful interpretation of a patient’s specific data. Consistency is difficult to obtain. In order to get a valid ultrasound for RA, you have to find just the right person to do the test. And it would seem that the stars must also be aligned…
Maybe we won’t really like having ultrasound tests for RA
Last week, I was reading a collection of radiological abstracts while doing research for a different project. I came across a study which shocked me. It was one of those “eureka” moments when I called out to whoever was home to come, “Look at this!”
The study reported that doctors changed plans for the treatment of Rheumatoid Arthritis patients after performing ultrasounds on the RA patients. Rheumatologists in this study were much less likely to prescribe disease modifying drugs for RA (DMARD’s) after the MUS test. “A total of 88.7% of patients had DMARD as a proposed management option before US vs. 48.4% after US (p<0.001). In addition, 4.84% of patients had NSAID/ review as outpatients as a proposed management option before US vs. 45.26% after US (p<0.001).”
The doctors had planned to prescribe DMARD’s based upon clinical examination, lab tests, and reports from the patients about their conditions. The results of the ultrasound tests changed the minds of almost half of the doctors so that they prescribed NSAID’s (glorified aspirin) instead, for treatment of the disease. Listen to the conclusion of the original report: “Conclusion: Sonography of the hands and/or feet significantly influences the rheumatologists’ diagnostic confidence in specific clinical findings and management plans.”
That influence is significant indeed. And it is not a positive influence in my opinion. I wish that patients’ descriptions of their own disease states had such influence.
Let’s not get lost in the woods
Aren’t “early and aggressive” the watchwords for treating Rheumatoid Arthritis? I’ve met some RA’ers whose doctors have seen evidence of their Rheumatoid Arthritis using ultrasound, enabling them to obtain treatment for RA which was creating invisible damage. Ultrasound tests have been especially valuable for RA’ers who are seronegative. Obviously, what we see in that last study describes an opposite scenario. Patients who would have been treated for Rheumatoid Arthritis will not receive treatments because of an ultrasound result.
When I read that, I suddenly had no desire for an ultrasound test for my RA. Would the doctor cut off my disease treating DMARD’s if he could not detect my RA with his MUS? Would he assume it was his own user error? How many docs do you know who usually see things that way?
Part 1 of this series, Ultrasounds for Rheumatoid Arthritis.
Recommended reading:
- More frustration: My Quest for Answers to Questions About Rheumatoid Arthritis
- More research: Palindromic Rheumatism Is Not a Rare Form of Rheumatoid Arthritis
- More questioning authority: Is There a Typical Rheumatoid Arthritis?
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Wow, very interesting. I’m one of those RAers for whom ultrasound confirmed the diagnosis and warranted the use of DMARDs. Early and aggressive. Well, actually, early diagnosis would have been 4-5 years earlier when my PCP first looked at possible lupus to explain troubles with my hands.
X-rays didn’t show bone erosion, but ultrasound did. I had RF all of a piddly 8 and SED rate of 31. Not exactly impressive numbers but six months of double doses of NSAIDs had done absolutely nothing for the pain. It took methotrexate to bring down the inflammation (and pain) to a mild level.
My rheumatologist is kinda funny. During the recent visit where we discussed Rituxan, she wrote me a new order for routine bloodwork. This time she actually left off any tests of inflammatory markers for concern that they would come back within the normal range and that insurance might contest the need for a more “big gun” medication. Smart lady.
I have never heard of that approach, but it sounds smart. That doc sounds like a keeper; I’d probably send her muffins!
That is interesting. I actually just joined an AS study as a remote participant to see if there is a genetic link suggesting severity of AS. I am excited to hear results!
How frustrating!! The results from that study make no sense. Such potential for good diagnostic use, but it shouldn’t be used to limit or deny needed treatment when other diagnostic methods indicate DMARDs.
YES! We have big job ahead of us to educate about RA; unfortunately that includes some doctors.
Kelly, I agree with the fact that the personnel involved in the testing should be highly trained in conducting the test. However, maybe this is because I am fortunate to live in an area that has a top national ranked rheumatology department, but the ultrasound tests that were conducted on me allowed even me to see the state of my disease. The wand that is used in the size of ball point pen. As he scaned each joint, the machine was turned to a color mode that actually would turn red when coming across the inflammation. He pointed out to me the areas that I already had erosions. My Dr. did not use any 1 of the tests ordered (blood, xrays, US) to make the diagnosis or determine the treatment plan. Again I will say this is probably due to established protocol at a hospital greatly involved in the advancement of treatments for RA. I guess, in a way, even though I knew from the pain, fatigue and mobility difficulties I had that what ever it was, it was widely spread, but actually gave me a chance to see things happening in joints I wasnn’t even aware were involved yet. I know you know that attitude of pushing through the pain and fatigue to accomplish things – especially for your kids. This was a wake-up call to me as to how important the treatments and rest in combination are to living daily with RA. I still am very stubborn about doings things for myself but as you may well know, it doesn’t take long for my body to remind me of its limitations!
That’s very interesting. I’m so glad for you. You are showing us the future / how it can be better. The test CAN be amazing as I said in part 1. But also terrifying as I showed in part 3.
Amy, we are in the same boat! I also push myself beyond the limits and after all this time you would think that I would know better…however, I am trying. Where do you live? I love that there are such protocols to give a definitive diagnosis and establish a course of treatment—what a concept! I live in Memphis and we have a limited amount of rheumys to begin with and they are still practicing in the Middle Ages. We still need to band together and force the drs to move ahead…Grace and Peace…
Great series Kelly, really great.
Thank you, Heather. So much work to make it sound simple but also present some evidence…
Kelly, I’m a technical editor. I have no idea how much time and work you put into your daily blogs, but I DO know it is much more than anyone would imagine. I know it is an enormous investment of your time; I would call it a sacrifice. rawarrior.com is a tremendous blessing to everyone who visits your site. Thank you for your dedication and hard work!
As one of my “catch up” things to do this weekend I plan on going back and reading all the blogs of yours I may have missed from time to time…because you clearly work so hard to get us wonderful information I don’t want to miss anything! I’m thankful for RA Warrior this year for sure
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Interesting. I’ve wondered about that in addition to use of MRI to detect MRI damage or activity that isn’t clinically obvious to the doctor. I did read something on an ER blog where the doc discussed how ultrasounds would and are useful in some ER situations but not used nearly as often as they should be.