Is Your Treatment Working?

In recent years, there has been increasing emphasis on using objective scores to monitor disease activity and decide when and if you need a change in treatment to bring RA under control. Although not always needed, ultrasound and MRI can help with those decisions.

“If your joints are tender and swollen and levels of inflammatory markers are elevated, your doctor doesn’t need modern imaging to know you aren’t doing well and it’s time to adjust your treatment,” says Dr. Conaghan.

For tracking joint damage, plain X-rays are still useful if your doctor can examine changes in your films over time, Dr. Conaghan adds.
Surprisingly, patients who seem to be doing well on a treatment may benefit most from modern imaging.

“After several months on a DMARD or biologic, a patient may be asymptomatic but you can tell the disease is not under control if you still see a thickened synovial lining with power Doppler,” says Dr. Machado.  

Because inflammation doesn’t entirely disappear even on the best therapy, a number of large studies are currently tracking patients’ progress over time to help determine what a “safe” level of imaging-visualized inflammation would be.. “These studies should also help us understand how to use these modern tools in everyday practice,” says Dr. Conaghan.

On a different research front, the biggest impact of modern imaging may be in streamlining clinical trials of new treatments.

Traditionally, the key indicator of a drug’s value is whether it limits joint damage on X-ray. At the ACR meeting in November 2012, Dr. Troum and colleagues presented validation by Systematic Literature Review that specific MRI findings could be used as indicators of RA damage in wrist and hand joints, finding the most support for MRI-visualized synovitis, bone marrow edema, and erosions.

“If MRI can accurately predict at 3 months what an X-ray will show in one or two years, that can cut the number of patients and the amount of time needed to test a new drug,” says Dr. Troum.

Access to Modern Imaging

The use of ultrasound in rheumatology practice was first widely adopted in Europe but is now gaining ground in the United States. In November 2012, the American College of Rheumatology published a report on reasonable uses of ultrasound in clinical practice. By reasonable, they mean that the health benefits exceed possible negative consequences by a wide margin (not taking cost into consideration).

Among multiple uses, the ACR panel endorsed applying ultrasound to the diagnosis and monitoring of RA in many joints, but they were clear that the technology is not a mandatory component of rheumatology practice. Recommendations on the use of MRI in RA are anticipated in 2013.

Both MRI and ultrasound are more expensive than X-rays. Medicare and several private insurers allow MRI or ultrasound to be used in the evaluation of extremity pain, not specifically to diagnose RA.