In part 1 of A Paradigm Shift in Rheumatoid Arthritis Disease Activity, we considered some reasons why better ways of considering RA disease activity are needed. Ideally, three key things should be considered regarding RA disease activity:
- The patient’s estimation of his disease activity (more here).
- Appropriate monitoring using available tests (read more here!)
- A more complete paradigm which includes various aspects of the disease.
Cartilage loss more significant than bone erosion or blood tests
Earlier this year, a Viennese study discussed the need for more attention to cartilage during RA diagnosis. The study, Physical disability in rheumatoid arthritis is associated with cartilage damage rather than bone destruction, published in the Annals of Rheumatic Diseases, showed that cartilage may be more important than bone erosion as a measure of disease.
In a related study, More attention needs to be paid for cartilage during RA diagnosis reported in News-medical.net, the possible paradigm shift is described:
“Until now, the focus lay mainly on investigating the damage to the bone. The study also revealed that the signs of joint swelling are given more attention than the results of blood tests… In the field of rheumatology, Europe leaves the USA, which is usually the leader in all things medical, behind – and in Europe, Vienna is regarded as ‘the’ leading centre for rheumatology… The results of the study show that in future more attention needs to be paid to the cartilage during diagnosis, for example during X-rays, while on the other hand treatment needs to be commenced earlier, and this includes preventative therapy… The researchers also found that an assessment of inflammatory activity using blood results does not always yield the most meaningful answers. This is particularly true if the blood results fail to detect any inflammatory markers, although inflamed joints are seen in the clinical examination…”
Importance of tenosynovitis with regard to RA disease activity
In another good sign, a study from Morocco A Comparison of Ultrasound and Clinical Examination in the Detection of Flexor Tenosynovitis in Early Arthritis investigated the detection of finger flexor tenosynovitis, another commonly overlooked aspect of RA. They compared clinical examination (by a rheumatologist) with ultrasound (in the hands of a proficient specialist). They concluded: “a negative clinical examination does not exclude inflammation and an US should be considered. Further work is recommended to standardize definitions and image acquisition for peritendinous inflammation for ultrasound.”
A Medscape article about the same tenosynovitis study says: “Tenosynovitis is widely accepted to be common in rheumatoid arthritis (RA) and postulated to be the first manifestation of RA, but its true prevalence in early disease and in particular the hand has not been firmly established.”
Why would we monitor what is going on in early disease?
Early disease can be a window of opportunity to provide early treatment that may be more likely to be effective. Bone and cartilage damage show up on x-rays at a later point. Some excerpts:
“There are limited published data on patients with early disease and very few using imaging in the hand. The reported prevalence of flexor tenosynovitis in RA is mainly based on studies involving clinical examination of patients with longstanding RA and varies from 5% to 55%… Another study demonstrated a high frequency of flexor tenosynovitis seen on MRI and US (64% joints, versus 28.5% joints)… Ultrasonography had higher sensitivity for detecting signs of inflammation in the examined finger joints than did clinical examination.”
If a clinician tells a patient, “You don’t look like you have any inflammation,” the odds are that you still do.
My rheumatologist once commented on doctors with that approach: “Just what does RA look like?”
Note: Emphases added.
Note 2: If you have any trouble opening the original study, paste the title and “published in Annals of the Rheumatic Diseases” into a Google search and click the top link.
Ultrasound series shows why it’s not commonly performed in the U.S. – yet!
- Ultrasound for Rheumatoid Arthritis, Part 1
- Ultrasounds for Rheumatoid Arthritis, Part 2
- Ultrasounds for Rheumatoid Arthritis, Part 3
- SEVERAL more posts on musculoskeletal ultrasounds
- Evidenced-based Medicine or Easy-bake Oven: Tension Between Evidence and Reality
- Rheumatoid Arthritis Swelling, Take Two
- 2 Reasons Monitoring Rheumatoid Arthritis Matters