L. Menza

A “new” technique for the diagnosis of chondrocalcinosis of the knee: sensitivity and specificity of high-frequency ultrasonography

According to the criteria proposed by Ryan and McCarty,1 the diagnosis of calcium pyrophosphate dihydrate (CPPD) deposition disease has been based on radiological evidence of the characteristic calcifications and on verification of the synovial liquid of CPPD crystals. Joint ultrasonography is an innocuous diagnostic technique that is well tolerated by patients, and is the elected method for observing calcified deposits in soft tissues.2 We carried out a longitudinal study, enrolling patients affected with ultrasonographic chondrocalcinosis according to previously proposed criteria3 from a sample of consecutive patients that came to our joint ultrasonography department for gonalgia (fig. 1). A total of 47 patients were identified, of which 14 had joint effusion. Figure 1  Hyperechoic deposits. Deposits (arrows) are shown that are compatible with calcium pyrophosphate dihydrate (CPPD) calcifications in the context of the synovial membrane (1), hyaline cartilage of the …

Ultrasound-detected tenosynovitis independently associates with patient-reported flare in patients with rheumatoid arthritis in clinical remission: results from the observational study STARTER of the Italian Society for Rheumatology

OBJECTIVES This study aimed to estimate the prevalence of US-detected tenosynovitis in RA patients in clinical remission and to explore its clinical correlates. METHODS A total of 427 RA patients in clinical remission were consecutively enrolled from 25 Italian rheumatology centres. Tenosynovitis and synovitis were scored by US grey scale (GS) and power Doppler (PD) semi-quantitative scoring systems at wrist and hand joints. Complete clinical assessment was performed by rheumatologists blinded to the US results. A flare questionnaire was used to assess unstable remission (primary outcome), HAQ for functional disability and radiographic erosions for damage (secondary outcomes). Cross-sectional relationships between the presence of each US finding and outcome variables are presented as odds ratios (ORs) and 95% CIs, both crude and adjusted for pre-specified confounders. RESULTS The prevalence of tenosynovitis in clinical remission was 52.5% (95% CI 0.48, 0.57) for GS and 22.7% (95% CI 0.19, 0.27) for PD, while the prevalence of synovitis was 71.6% (95% CI 0.67, 0.76) for GS and 42% (95% CI 0.37, 0.47) for PD. Among clinical correlates, PD tenosynovitis associated with lower remission duration and morning stiffness while PD synovitis did not. Only PD tenosynovitis showed a significant association with the flare questionnaire [OR 1.95 (95% CI 1.17, 3.26)]. No cross-sectional associations were found with the HAQ. The presence of radiographic erosions associated with GS and PD synovitis but not with tenosynovitis. CONCLUSIONS US-detected tenosynovitis is a frequent finding in RA patients in clinical remission and associates with unstable remission.

SAT0061 Concurrent Ultrasound-Detected Synovitis and Tenosynovitis Predict Flare in Patients with Rheumatoid Arthritis in Clinical Remission

Background Subclinical synovial inflammation detected by ultrasonography (US) in patients with rheumatoid arthritis (RA) in clinical remission relates to disease flare. The impact of tenosynovitis in this context is not known. Objectives To evaluate the association between US-detected tenosynovitis and synovitis in RA patients in clinical remission and flare over 12-months. Methods STARTER is a multicentre cohort study of the US Study Group of the Italian Society for Rheumatology. Participants were selected on the basis of a reliability exercise and the availability of high-end equipment. Patients with RA in clinical remission underwent clinical evaluation and US synovitis (-S) and tenosynovitis (-T) were assessed categorically for Grey Scale (GS) and power Doppler (PD) at 11 joints, extensor and flexor tendons in both hands and wrists. Patients were seen at 6 and 12 months. Flare within 12 months was defined as increase of >1.2 or >0.6 if final DAS28>3.2. The relationship between the presence of GS-T/-S, PD-T/-S was evaluated by logistic models, presented as odds ratios (OR) and 95% confidence interval (CI), adjusted for pre-specified confounders. Results 361 patients (72.3% f, mean age (sd) 56.1 (13.3), median disease duration (IQR) 7.1 years (3.6–13.5)) were included. 98/326 (30.6%) patients had a flare within 12 months. Considering US variables separately, only PD-S significantly predicted flare (OR 1.87 (1.12,3.14)). When the model included both –T and –S, only the concurrent presence of –T and –S predicted flare (PD-T+-S: OR 2.06 (1.04, 4.07); GS-T+-S: OR 2.27, (1.01,5.10)), while isolated –S and –T did not. Conclusions In patients with RA in clinical remission, US-detected synovial and tenosynovial inflammation identifies patients at risk of flare. US might help decisions on management in this population. Disclosure of Interest None declared

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

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.

OP0217 Ultrasound-Detected Synovitis and Tenosynovitis Independently Associate with Flare in Patients with Rheumatoid Arthritis in Clinical Remission

Background Remission is the target of treatment in rheumatoid arthritis (RA). In clinically-defined remission, subclinical disease activity may persist leading to flare and joint damage progression. Musculoskeletal ultrasonography (MSUS) is a good candidate to overcome the limitations of clinimetric indexes. The role of MSUS synovitis is well-known in the literature but no data are available for tenosynovitis. Objectives The study aims to evaluate the association between US synovitis (S) and tenosynovitis (T) and 6-month flare in RA patients in clinical remission. Methods The STARTER study is a multicentre cohort study promoted by the Italian Society for Rheumatology. Ultrasonographers were selected by an inter-reader reliability exercise. Consecutive patients with RA and clinical remission underwent a full clinical evaluation and Grey Scale (GS) and power Doppler (PD) US exam (assessing -S and -T) at wrists, MCP, PIP and extensor/flexor tendon sheets. Six-month flare was defined as: 1) increase of >1.2 or >0.6 if final DAS28>3.2; 2) change in treatment; 3) change of >4 points in the flare questionnaire (FQ) if FQ<4 at baseline. The relationships between presence of GS-T/-S, PD-T/-S were evaluated by logistic models, presented as odds ratios (OR) and 95%CI, adjusted for pre-specified confounders. Results A total of 427 patients were included in the analyses: 113 (26.5%) men, mean (SD) age 56.6 (13.4), median (IQR) disease duration 7.3 (3.8-13.5) years, median (IQR) remission duration 12 (8-24) months, RF positive 287 (67.4%), mean (SD) DAS28 2.2 (0.8), median (IQR) HAQ 0.125 (0-0.375), on DMARDs 322 (75.4%), on biologics 183 (42.9%), on glucocorticoids 187 (43.8%). GS-T was present in 198/373 (53.1%) patients, PD-T in 88/372 (23.7%) while GS-S in 270/368 (73.4%) and PD-S in 171/372 (46.5%). The association between US variables and flare is reported in the Table. Conclusions MSUS PD-S confirms its predictivity on flare defined according to DAS28 definitions while PD-T is more specifically associated with patient-related flare and symptoms exacerbation. US-T should be take into account in the management of RA patients in clinical remission. Disclosure of Interest None declared

THU0281 Efficacy of etanercept therapy with an every other week regimen in patients with ankylosing spondylitis

Background Efficacy and safety of etanercept 25 mg twice weekly was comparable to 50 mg once weekly in adult patients with ankylosing spondylitis (AS). We know that AS patient who were treated initially with Etanercept 25 mg twice weekly could be switched to once weekly but with increased dose per injection at 50 mg. Howeverrecent evidences suggest that etanercept 25 mg once weekly is effective enough to maintain remission for AS among korean patients. In addition discontinuation of etanercept 25 mg usually results in the relapse of disease activity but only after some weeks inAS patients in remission. Objectives To evaluate if patients with AS in remission with biweekly etanercept therapy could be switched to an every-other-week regimen,without increased dose per injection. Methods 38 patients with AS diagnosed at least from 1 year were enrolled, according to the modified 1984 New York Criteria for ASwith by minor to moderate radiographic evidence of spinal structural damage (Stage I-III). All patients had active AS (BASDAI>or=4), despite treatment with NSAIDs. Exclusion criteria included the presence of significant comorbidities, including active infection, cardiac insufficiency (NYHA class III/IV),malignancy, elevated liver enzymes, creatinine serum level >1,20 mg/l, alcohol and/or drug abuse, pregnancy, demyelinating diseases. Before being recruited for the study, patients were screenedfor latent tuberculosisandfor viral hepatitis. Patients meeting the inclusion and exclusion criteria self-administered 25 mg of etanercept (Wyett) subcutaneously twice weekly for sixteen weeks.According to the protocol,patient withclinical remission (defined as ASAS criteria and BASDAI<2) were switched to an weekly etanercept regimen without a change in dose at weeks 12 and 16 and to an every-other-week regimen at week 24. A follow-up was performed at week 36 and 48 to evaluate clinical efficacy.In case of a relapse of the disease activity etanercept 25 mg twice a week were administered again. Results All patients received for 16 weeks a dose of 25 mg twice a week.The percentage of ASAS 20 responders was 81% (31 patients). Among them, 18 (47,3%)with persistent remission (week 12 and 16) were switched to an weekly regimen without a change in dose, while the other 13continued with biweekly etanercept therapy. At week 24, 15 patients (85%) were stable and among them 14 patients (93%) had clinical efficacy at week 36 and 54. At week 24, 3 patients (15%) did not show beneficial effects and they continued with etanercept 25 mg twice a week. There were no statistically significant differences in the incidence of adverse events between the biweekly etanercept therapy group (16 pt) and the every-other-week etanercept therapy group (14 pt). Baseline characteristics associated with a major clinical response to etanercept were a shorter disease duration, younger age, raised CRP and a higher BASDAI. Conclusions Our study indicatesthat a consistent percentage of subjectswith AS (37%), differently from RA, treated with etanercept,maintains the remission also with an every-other-week regimen. Thisfinding may suggest that the AS patients in clinical remission with biweekly etanercept could be switched to an every-other-week regimen, without increased dose per injection, with relevant lowering of economic andsafety burden. Disclosure of Interest None Declared