Ultrasound in the evaluation of rheumatoid arthritis.

In the last two decades, ultrasound has been fully implemented in the diagnosis and management of rheumatoid arthritis. Several studies have been published that have demonstrated better availability of this technique in the identification of elementary inflammatory joint and tendon injuries, as joint and tendon sheath synovial hypertrophy, joint effusion, and Power Doppler signal. Ultrasonography has good properties to identify changes with different treatments, have predictive value for relapse in patients in clinical remission and in structural damage. Furthermore, ultrasound tools have been developed that allow prospective evaluation of patients. Joint and tendon ultrasound evaluation indexes have been used for disease diagnosis and monitoring. Initially, indexes have been integrated only for joint, but more recently have appeared mixed indexes, integrated for ultrasound evaluation and other types of variables. There are still important objectives to be achieved to complete the development of ultrasound in rheumatoid arthritis, which makes ultrasound a great aid tool in decision-making in clinical practice.

Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis.

OBJECTIVE: We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS: Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS: The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS: This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.

Interobserver reliability of Masei index validation by a multicenter collaborative group of rheumatologists.

MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis.

OBJECTIVE: We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS: Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS: The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS: This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.

Analysis of the correlation between disease activity score 28 and its ultrasonographic equivalent in rheumatoid arthritis patients.

OBJECTIVE: To study the differences between disease activity score 28 (DAS28) index and an ultrasound (US) approach using index echographic disease activity score (ECODAS). METHODS: This was a cross-sectional study in patients diagnosed with rheumatoid arthritis (RA). Demographic, clinical, and laboratory data were collected. We created a US index (ECODAS) evaluating the joints with synovitis using gray scale US (GSUS) and power Doppler US (PDUS) and calculated the formula of DAS28 index with both variables substituting tender joint for GSUS and swollen joint for PDUS (ECODAS1) and vice versa (ECODAS2). RESULTS: A total of 58 patients (65.5% women and 34.5% men) were included in the study. There was no significant difference between the 2 US indexes. We obtained a Pearson's correlation coefficient (Pearson's r) of 0.56 (p<0.00001) between DAS28 and ECODAS1 and of 0.57 (p<0.00001) between DAS28 and ECODAS2, respectively. However, for patients with a high disease activity [DAS28>5.1, tender joint count (TJC, high)], the correlation was poor (0.18) and ECODAS indexes were significantly lower (p=0.001). The correlation increased (0.86, p<0.001) when we excluded the tender joints and the joints with GS-positive synovitis in both the scores. CONCLUSION: US reduces the bias in the evaluation of patients with RA with a high value in DAS28 index. We found a clear difference between DAS and ECODAS when TJC was high. The results suggest that joint tenderness reported by the patient is not a good reflection of inflammation. More studies are needed to find a new combined clinical and sonographic index that would better assess the disease activity in patients with RA.