Background Prevalence of Obesity is on rise and it is prevalent in 25-30 % of adult UK population. The mean DAS28 scores increases with increasing BMI from normal to overweight and obese, among women. Clinical assessment by DAS28 may overestimate disease activity (subjective parameters such as tender joint counts (TJC) depend on a patient’s pain threshold and coexistent conditions, eg, osteoarthritis and fibromyalgia).Prevalance of secondary fibromyalgia in established inflammatory arthritis (IA)is 7-10%. However, Treat to Target guidance has highlighted importance of remission in inflammatory arthritis patient group. Clinical remission defined by DAS28 doesn’t always mean complete absence of inflammatory activity if measured by MSK US. Our IA DMARD non responders and their clinical disease activity (DAS 28 ) analysed with use of MSK US.
Objectives Appropriate IA patients selection for biologics in high BMI and secondary fibromyaglia group with routine use of MSK US.
Methods We analysed images and reports of MUS examinations of 48 patients, sent by three rheumatologist between March’12 and September 2012 for established diagnosis of IA as per ACR criteria. MSK radiologist defined synovitis using both Gray scale(GS) and Power Doppler using OMERACT criteria. patients had moderate to high disease activity despite using at least two DMARD or combination DMARDs. MCP’s, PIP’s and /or Wrists US assessment were performed for them.36 were female and 12/36(33%) of them had BMI ( Body Mass Index) >30 and out of them 4/36 (11%) had BMI >40.24/48 (50%) were RhF positive and 10/48 (21%) ACPAb positive. Mean age 48.6 years and disease duration was 2.1 years. Data were gathered for each patient including clinical diagnosis, age, BMI, duration of disease, information of previous DMARDs, RhF and ACPAb status, DAS28.
Results All these patients were biologics naive.36/48 on Methotrexate, 30/48 on Sulfaslasazine, 18/48 Leflunomide, 15/48 Hydroxychloroquine. Mean DAS28 in BMI<30 group (33/48)was 4.8 ( 3.85 -5.92 ) and Mean DAS28 for BMI >30 (15/48) group was 5.20 (4.8 - 6.10). BMI >30 group 80% showed low probability of synovitis (Grade 0- 1) and 10/15 had DAS28 >5.1. BMI <30 group, 18% showed moderate to high probability of synovitis ( Grade2- 3 ) and mean DAS28 of them was 3.9 while 82% showed intermediate probability of synovitis ( Grade 1-2)with mean DAS28 .4.5
Conclusions MSK US assessment should be considered in high BMI group and in patients with secondary fibromyalgia with high DAS28 in IA patients before escalating treatment with biologics. Clinically moderate DAS28 may show aggressive synovitis in US assessment and targeting them appropriately with treat to target guidance may prevent further joint damage. Secondary fibromyalgia in established inflammatory arthritis should be identified in treatment non responders before escalating to biologics inappropriately
Jawaheer D, et al; QUEST-RA.Gender, body mass index and rheumatoid arthritis disease activity: results from the QUEST-RA Study
Richard J Wakefi eld et al treat-to-target: can a targeted ultrasound initiative improve RA outcomes?
Lee YC et al Incidence and predictors of secondary fibromyalgia in an early arthritis cohort.
Acknowledgements No confict of interest.
Disclosure of Interest None Declared