María Pilar Lisbona

Sacroiliitis Associated with Axial Spondyloarthropathy: New Concepts and Latest Trends

The sacroiliac joints are involved in most cases of axial spondyloarthropathy, the first manifestation usually being sacroiliitis. A finding of sacroiliitis at radiography is the classic diagnostic hallmark of axial spondyloarthropathy. However, radiographic changes reflect structural damage rather than active inflammation, which may delay the diagnosis by several years. In the past decade, the field of spondyloarthropathy has undergone major changes, largely driven by the development of new drugs for the treatment of ankylosing spondylitis. In recent years, the Assessment of SpondyloArthritis international Society has focused on the reassessment of existing classification criteria and the development and validation of diagnostic tools to facilitate early diagnosis and assessment of treatment response. Magnetic resonance (MR) imaging is the most recent innovation and the important change with respect to the previously established classification criteria. This modality has become an integral part of managing patients with sacroiliitis. MR imaging can serve as a biomarker of disease activity, allows monitoring, and can provide guidance for the treatment of affected patients, and it will likely become even more central to the care of these patients. Familiarity with the anatomy, anatomic variants, and physiologic changes of the sacroiliac joints is important for correctly interpreting findings and avoiding misdiagnosis.

Rapid reduction in tenosynovitis of the wrist and fingers evaluated by MRI in patients with rheumatoid arthritis after treatment with etanercept

Objective To assess the efficacy of etanercept in reducing tenosynovitis evaluated by MRI of the hand (h-MRI) in patients with active rheumatoid arthritis (RA) refractory to disease-modifying antirheumatic drug (DMARD) after 6 weeks of treatment. Methods 31 patients with active RA defined by a disease activity score (DAS28) >3.2 and synovitis in the hands were randomised into two groups: 19 patients received 50 mg weekly subcutaneous etanercept added to previous DMARD treatment and 12 patients continued with previous DMARD therapy. Clinical evaluation, blood tests, functional capacity evaluation and h-MRI were performed at the start of the investigation and at week 6. Tenosynovitis was evaluated on T1-weighted sequences with fat suppression after gadolinium as the presence of a peritendinous signal enhancement on axial images using a new method including wrist and finger tendons. The reliability, sensitivity to change and responsiveness of this method were also evaluated. Results Scores for tenosynovitis showed a significant reduction in the etanercept group compared with placebo (p=0.01) after 6 weeks of treatment. Adding MRI joint synovitis to tenosynovitis scores gave an even higher significant reduction in the etanercept group (p=0.007). A positive and statistically significant correlation between tenosynovitis and DAS28, erythrocyte sedimentation rate and C-reactive protein was found, but not with functional capacity. Responsiveness for tenosynovitis was small but was higher when joint synovitis scores were added. Conclusion Addition of etanercept significantly reduced MRI tenosynovitis of the wrist and fingers in patients with active RA refractory to DMARD treatment. The method of scoring tenosynovitis showed good reliability and moderate responsiveness.

Hand and wrist arthralgia in systemic lupus erythematosus is associated to ultrasonographic abnormalities

OBJECTIVE Systemic lupus erythematosus (SLE) is an autoimmune disease which may has joint impairment. Often, SLE patients complain of hand and wrist arthralgia (HA). Usually, these patients do not show any swelling in the physical exam. Our aim was to demonstrate Power Doppler Ultrasound (PDUS) abnormalities in SLE patients with HA. METHODS We recruited 58 consecutive SLE patients and divided them into two groups: case group (n = 28) were patients with HA, and control group (n = 30) were patients without HA. We also collected socio-demographic and disease activity data, biological markers and SLEDAI index. We evaluated disability and quality of life by mHAQ and SF-12, respectively. We performed a bilateral hand and wrist PDUS on all patients. PDUS findings were based in OMERACT-7 group criteria. RESULTS We found PDUS abnormalities in most of SLE patients who suffered HA, when compared to SLE controls (P < 0.001). The main findings in Case Group were: tenosynovitis (39.2%), synovial effusion or hypertrophy (25%) and active synovitis (14.2%). SLEDAI score and dsDNA antibodies were related to the presence of PDUS abnormalities (P < 0.05 and P < 0.001, respectively). We also found worse physical SF-12 (P < 0.05) and mHAQ (NS) scores in case group. CONCLUSIONS SLE patients who present HA have more PDUS abnormalities. These findings are associated with a higher SLEDAI score and dsDNA antibodies. This articular affection may contribute to a worsened functional ability and a lower quality of life. PDUS seems to be a reliable tool in the assessment of SLE patients with HA.

Association of Bone Edema with the Progression of Bone Erosions Quantified by Hand Magnetic Resonance Imaging in Patients with Rheumatoid Arthritis in Remission

Objective. To evaluate the association of synovitis, bone marrow edema (BME), and tenosynovitis in the progression of erosions quantified by hand magnetic resonance imaging (MRI) at 1 year in patients with early rheumatoid arthritis (RA) in remission. Methods. A total of 56 of 196 patients with early RA in remission at 1 year and with available MRI data at baseline and at 12 months were included. MRI images were assessed according to the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) system. Persistent remission was defined as 28-joint Disease Activity Score-erythrocyte sedimentation rate ≤ 2.6 and/or Simplified Disease Activity Index ≤ 3.3 and/or the new boolean American College of Rheumatology/European League Against Rheumatism remission criteria for a continuous period of at least 6 months. Progression of bone erosions was defined as an increase of 1 or more units in annual RAMRIS score for erosions compared to baseline. Results. At 1 year, the majority of patients with RA in sustained remission showed some inflammatory activity on MRI (94.6% synovitis, 46.4% BME, and 58.9% tenosynovitis) and 19 of the 56 patients (33.9%) showed MRI progression of bone erosions. A significant difference was observed in MRI BME at 1 year, with higher mean score in patients with progression compared to nonprogression of erosions (4.8 ± 5.6 and 1.4 ± 2.6, p = 0.03). Conclusion. Subclinical inflammation was identified by MRI in 96.4% of patients with RA in sustained clinical remission. Significantly higher scores of BME after sustained remission were observed in patients with progression of erosions compared to patients with no progression. The persistence of higher scores of BME may explain the progression of bone erosions in patients with persistent clinical remission.

Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con artritis reumatoide

OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). METHODS Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and MRI in RA patients.

Reactivación del virus de la hepatitis B en un paciente con artritis reumatoide tras el tratamiento con rituximab

The reactivation of hepatitis B virus (HBV) infection is defined as an increase in HBV replication in a patient with an inactive or resolved hepatitis (usually accompanied by increased serum transaminase levels). Most reported cases have occurred in patients with hematologic malignancies after chemotherapy.1–3 Recently, there have been reports of HBV reactivation in patients with rheumatoid arthritis after treatment with biological therapies such as rituximab (RTX)4,5 (Table 1). Although most cases of HBV reactivation have occurred in patients with serology indicating chronic HBV infection, patients with resolved HBV infection can develop this complication.5 We report the case of a 77 year old patient with a history of seropositive and erosive rheumatoid arthritis of 12 years of evolution, receiving the first cycle of RTX in February 2008. Serology for HBV in 2001 was HBsAg negative and anti-HBc positive, compatible with resolved hepatitis B. The patient received methotrexate from 2002 to 2004 and the treatment was stopped by the appearance of oral ulcers. In 2005, treatment was started with infliximab 3 mg/kg every 8 weeks with good response; after one year of treatment, the patient presented a lack of response in March 2006 and it was suspended due to multiple episodes of lung infections and switched to etanercept 50 mg weekly. From 2005 to 2008, serum levels of ALT transaminase (GPT) ansd AST (GOT), remained stable, but new virus serology was not requested. Due to poor control of symptoms (disease activity score [DAS] 28 joints 6.43) the patient

ACR/EULAR Definitions of Remission Are Associated with Lower Residual Inflammatory Activity Compared with DAS28 Remission on Hand MRI in Rheumatoid Arthritis

Objective. To determine the level of residual inflammation [synovitis, bone marrow edema (BME), tenosynovitis, and total inflammation] quantified by hand magnetic resonance imaging (h-MRI) in patients with rheumatoid arthritis (RA) in remission according to 3 different definitions of clinical remission, and to compare these remission definitions. Methods. A cross-sectional study. To assess the level of residual MRI inflammation in remission, cutoff levels associated to remission and median scores of MRI residual inflammatory lesions were calculated. Data from an MRI register of patients with RA who have various levels of disease activity were used. These were used for the analyses: synovitis, BME according to the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring system, tenosynovitis, total inflammation, and disease activity composite measures recorded at the time of MRI. Receiver-operating characteristic analysis was used to identify the best cutoffs associated with remission for each inflammatory lesion on h-MRI. Median values of each inflammatory lesion for each definition of remission were also calculated. Results. A total of 388 h-MRI sets of patients with RA with different levels of disease activity, 130 in remission, were included. Cutoff values associated with remission according to the Simplified Disease Activity Index (SDAI) ≤ 3.3 and the Boolean American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) definitions for BME and tenosynovitis (1 and 3, respectively) were lower than BME and tenosynovitis (2 and 5, respectively) for the Disease Activity Score on 28 joints (DAS28) ≤ 2.6. Median scores for synovitis, BME, and total inflammation were also lower for the SDAI and Boolean ACR/EULAR remission criteria compared with DAS28. Conclusion. Patients with RA in remission according to the SDAI and Boolean ACR/EULAR definitions showed lower levels of MRI-detected residual inflammation compared with DAS28.

Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con espondiloartritis, incluyendo la artritis psoriásica, y en pacientes con artritis idiopática juvenil

OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging in patients with spondyloarthritis, including psoriatic arthritis, and juvenile idiopathic arthritis. METHODS Recommendations were generated following a nominal group technique. A panel of experts (15 rheumatologists and 3 radiologists) was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of participants voted≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 12 recommendations were proposed for each disease. They include, along with explanations of the validity of US and magnetic resonance imaging regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and magnetic resonance imaging in patients with spondyloarthritis and juvenile idiopathic arthritis.

THU0461-HPR Global assessment of disease by the patient in the new ACR/EULAR remission criteria: Why do not fulfil the remission?

Background Recently, new criteria has been described for assessing Rheumatoid Arthritis (RA) remission. However, in clinical practice, patients who may be in remission by these criteria (ACR/EULAR 2011), ofter fail to meet patient’s global assessment (PtGA) scale of 0 to 10 with a value less than or equal to 1. Objectives To evaluate in patients with rheumatoid arthritis (RA), the reasons for non compliance with the new remission criteria ACR/EULAR due to a high PtGA and not related to the activity of the RA. Methods We included consecutively from April to December 2011 all patients with RA in remission for the composite index of activity, simplified disease activity index (SDAI) ≤3.3 and swollen joint count (SJC) ≤1, tender joint count (TJC) ≤1, C-reactive protein (CRP) ≤1 mg/dl but with PtGA >1 cm. Demographic variables (date of birth, sex, educational level), disease (date of diagnosis of RA, presence of radiological erosions, serum levels of RF and ACPA), activity DAS28, VAS pain (0-10 cm), PtGA (0-10 cm), functional disability by HAQ, treatment (corticosteroids, DMARDs and/or tumor necrosis factor (anti-TNF), and comorbidity not associated with RA as possible causes of a PtGA>1 cm. Data were analyzed with SPSS v.15. Results 55 patients (87.3% women) with a mean age of 57.8±12.7 years and a mean disease duration of 4.2±3.1 years were included. 60% were seropositive for rheumatoid factor (RF), 61.8% for Anti-citrullinated protein antibodies (ACPA) and 87.3% had radiographic erosions. 20% of patients had basic studiesand only 16.4% medium-high level. The mean HAQ was 0.483±0.387. 80% were treated with DMARDs (47.3% methotrexate), a 34.5% anti-TNF with or whithout DMARDs, 52.8% were taken corticosteroids (mean dose to prednisone equivalent of 2.1±2.2 mg per day). The mean DAS28 was 2.3±0.5, the pain VAS 3.6±1.8 cm and 3.7 ± PtGA was 1.2 cm. Acute phase reactants were both below normal level (ESR=16.5±14.7 (normal <37 mm/h) and CRP=0.3±0.2 (normal <0.8mg/dl). The reasons why patients considered to be in remission (new ACR/EULAR criteria) did not meet a PtGA ≤1 cm is shown in Table 1. Table 1. Main causes of PtGA of >1 cm in patients with RA and in remission Causes No. of patients (%) Osteoarthritis 24 (43.7%) Fibromyalgia 3 (5.4%) Soft Tissue Rheumatism 9 (16.4%) Intercurrent Process (surgery, trauma, infection ...) 5 (9.1%) Psychological disorder 3 (5.4%) Awareness of chronic disease 6 (10.9%) Comorbidity not associated 5 (9.1%) Conclusions In our series, 65.5% of the patients on remission by other components if the new ACR/EULAR criteria, reported a PtGA >1 cm due to a non-RA joint disease, osteoarthritis and soft tissue rheumatism being most prevalent disorders. The Rheumatology nurse should ensure proper completion of visual analog scales especially the PtGA in patients with RA as it is an important variable in the index of activity and remission of the disease. Disclosure of Interest None Declared

Retraso diagnóstico y terapéutico de la artritis reumatoide y su relación con dispositivos asistenciales en Catalunya. Estudio AUDIT

OBJECTIVE Diagnosis and therapy of patients with early onset rheumatoid arthritis (RA) is influenced by accessibility to specialized care devices. We attempted to analyze the impact of their availability. METHODS We analyzed time related to diagnosis delay measuring: 1) Time from first clinical symptoms to the first visit with the Rheumatologist; 2) Time from referral to the first visit of Rheumatology; 3) Time between first symptom until final diagnosis; 4) time between first symptom until the initiation of the first disease-modifying antirheumatic drug (DMARD). The presence of these 6 rheumatology devices was defined: 1) early arthritis monographic clinics, 2) RA monographic clinics, 3) Mechanisms for fast programming, 4) Algorithms for referral from primary care (PC), 5) rheumatology consultation services in PC and 6) consulting services in PC. RESULTS The mean time from onset of symptoms to diagnosis or the establishment of a DMARD in RA patients in Catalonia is very long (11 months). Patients seen in rheumatology devices such as RA monographic clinics, rheumatology consultation in PC and specially in early arthritis clinics are treated early with DMARDs. CONCLUSION the existence of monographic clinics or consulting in primary care centers is essential to improve early care of RA patients.