Twenty years ago, prior to the introduction of effective structure modifying treatments for RA, rheumatologists had little use for imaging in daily practice. Why gather detailed anatomical information if it wasn't going to substantively affect patient management? The success of the biologics revolution and introduction of treat-to-target management has changed that, however, and rheumatologists today increasingly use advanced imaging techniques, beyond conventional radiography, to manage their patients.
Radiography has been the mainstay of imaging evaluation of RA for decades, but it's ability to probe structural damage is limited to only bone erosions and joint-space narrowing; it cannot not directly identify damage to tendons or ligaments nor visualize the upstream inflammatory drivers of tissue damage (synovitis, ostietis, ethesitis, tenosynovitis/tendointis). Radiography is also relatively insensitive to change; typically six to twelve months are necessary to demonstrate progression reliably. MRI is more sensitive for bone erosion and cartilage loss than radiography is, and therefore can identify patients with the erosive phenotype much earlier in the course of their disease and direct them to appropriate therapy sooner. MRI can detect progression of bone erosion and cartilage loss in as little as 3 months, and suppression of synovitis and osteitis in only 2 weeks. Ultrasound also can detect bone erosion more sensitively than radiography can, and it also can visualize synovitis and tenosynovitis/tendonitis directly. Composite clinical measures of disease activity, such as DAS28, SDAI and CDAI are responsive to treatment, but they often fail to identify patients who continue to progress structurally despite satisfying clinical criteria for remission. MRI and ultrasound can therefore serve as useful adjuncts to clinical measures in treat-to-target patient management.
This presentation will review in detail the relative strengths and weaknesses of radiography, MRI and ultrasound in these roles, and provide recommendations for their use in clinical practice.
Disclosure of Interest C. Peterfy Shareholder of: Spire Sciences, Inc., Consultant for: AbbVie, Amgen, Acerta, AstraZeneca, Bristol Myers Squibb, Celgene, Five Prime, Genentech, Lilly, Medimmune, Merck, Novartis, Pfizer, Roche, Salix-Santaris, Samsung, Employee of: Spire Sciences, Inc., Speakers bureau: Amgen