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The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study
  1. Georgios Filippou1,
  2. Garifallia Sakellariou2,
  3. Carlo Alberto Scirè1,3,
  4. Greta Carrara3,
  5. Federica Rumi3,
  6. Emanuela Bellis4,
  7. Antonella Adinolfi5,
  8. Alberto Batticciotto6,
  9. Alessandra Bortoluzzi1,
  10. Giovanni Cagnotto7,
  11. Marta Caprioli8,
  12. Marco Canzoni9,
  13. Francesco Paolo Cavatorta10,
  14. Orazio De Lucia11,
  15. Valentina Di Sabatino5,
  16. Antonella Draghessi12,
  17. Ilaria Farina1,
  18. Maria Cristina Focherini13,
  19. Alessandra Gabba14,
  20. Marwin Gutierrez15,
  21. Luca Idolazzi16,
  22. Filippo Luccioli17,
  23. Pierluigi Macchioni18,
  24. Marco Sergio Massarotti19,
  25. Claudio Mastaglio20,
  26. Luana Menza20,
  27. Maurizio Muratore21,
  28. Simone Parisi22,
  29. Valentina Picerno23,
  30. Matteo Piga14,
  31. Roberta Ramonda24,
  32. Bernd Raffeiner25,
  33. Daniela Rossi26,
  34. Silvia Rossi2,
  35. Paola Rossini27,
  36. Crescenzio Scioscia28,
  37. Carlo Venditti29,
  38. Alessandro Volpe10,
  39. Annamaria Iagnocco30
  1. 1 Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
  2. 2 Chair and Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
  3. 3 Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
  4. 4 Rheumatology Unit, Mauriziano Hospital, Turin, Italy
  5. 5 Department of Medicine, Surgery and Neurosciences, Rheumatology Section, University of Siena, Siena, Italy
  6. 6 Rheumatology Department, Luigi Sacco University Hospital, Milan, Italy
  7. 7 Department of Clinical Sciences, Rheumatology, Skane University Hospital, Lund University, Lund, Sweden
  8. 8 Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Italy
  9. 9 Rheumatology Unit, Azienda Ospedaliera Sant’Andrea, Rome, Italy
  10. 10 Rheumatology Unit, A.O.U.P. Santa Chiara, Trento, Italy
  11. 11 Department of Rheumatology, ASST Centro Traumatologico Ortopedico G. Pini-CTO, Milan, Italy
  12. 12 Department of Rheumatology, Clinica Reumatologica, Universita` Policlinica delle Marche, Jesi, Italy
  13. 13 Rheumatology Unit, Infermi Hospital, Rimini, Italy
  14. 14 Rheumatology Unit, A.O.U. University Clinic Cagliari, Monserrato, Italy
  15. 15 Instituto Nacional de Rehabilitación, Mexico City, Mexico
  16. 16 Rheumatology Unit, Ospedale Civile Maggiore, Verona, Italy
  17. 17 Rheumatology Unit, A.O.S. Maria della Misericordia, Perugia, Italy
  18. 18 Rheumatology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
  19. 19 Department of Rheumatology, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
  20. 20 Rheumatology Unit, Moriggia-Pelascini Hospital, Gravedona, Italy
  21. 21 Rheumatology Unit, A. Galateo Hospital, San Cesario di Lecce, Italy
  22. 22 SC Reumatologia, A.O.U.Citta` della Salute e della Scienza di Torino, Turin, Italy
  23. 23 Rheumatology Unit, Azienda Ospedaliera Regionale San Carlo, Potenza, Basilicata, Italy
  24. 24 Rheumatology Unit, Department of Medicine, DIMED, University of Padova, Padua, Italy
  25. 25 Rheumatology Unit, Bolzano Hospital, Bolzano, Italy
  26. 26 SS Immunoreumatologia, G. Bosco Hospital, Turin, Italy
  27. 27 Rheumatology Unit, P. O. Destra Secchia, Pieve di Coriano, Italy
  28. 28 DIM Sezione di Reumatologia, Policlinico Universitario di Bari, Bari, Italy
  29. 29 Rheumatology Unit, A.O. Rummo di Benevento, Benevento, Italy
  30. 30 Dipartimento di Scienze Cliniche e Biologiche, Universita` degli Studi di Torino, Turin, Italy
  1. Correspondence to Professor Annamaria Iagnocco; annamaria.iagnocco1{at}


Objective To define the role of ultrasound (US) for the assessment of patients with rheumatoid arthritis (RA) in clinical remission, including joint and tendon evaluation.

Methods A multicentre longitudinal study has been promoted by the US Study Group of the Italian Society for Rheumatology. 25 Italian centres participated, enrolling consecutive patients with RA in clinical remission. All patients underwent complete clinical assessment (demographic data, disease characteristics, laboratory exams, clinical assessment of 28 joints and patient/physician-reported outcomes) and Power Doppler (PD) US evaluation of wrist, metacarpalphalangeal joints, proximal interphalangeal joints and synovial tendons of the hands and wrists at enrolment, 6 and 12 months. The association between clinical and US variables with flare, disability and radiographic progression was evaluated by univariable and adjusted logistic regression models.

Results 361 patients were enrolled, the mean age was 56.20 (±13.31) years and 261 were women, with a mean disease duration of 9.75 (±8.07) years. In the 12 months follow-up, 98/326 (30.1%) patients presented a disease flare. The concurrent presence of PD positive tenosynovitis and joint synovitis predicted disease flare, with an OR (95% CI) of 2.75 (1.45 to 5.20) in crude analyses and 2.09 (1.06 to 4.13) in adjusted analyses. US variables did not predict the worsening of function or radiographic progression. US was able to predict flare at 12 months but not at 6 months.

Conclusions PD positivity in tendons and joints is an independent risk factor of flare in patients with RA in clinical remission. Musculoskeletal ultrasound evaluation is a valuable tool to monitor and help decision making in patients with RA in clinical remission.

  • ultrasonography
  • rheumatoid arthritis
  • disease activity
  • treatment

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  • GF and GS contributed equally.

  • Handling editor Josef S Smolen

  • Contributors GF and GS contributed equally to interpretation of data and drafting the work. CAS, GC and FR contributed equally to study design and analysis of data. All authors contributed to the acquisition of data, revising critically the work, approved the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None required.

  • Patient consent Obtained.

  • Ethics approval The local ethics committee of each participating centre.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.