San Francisco, CA—Ultrasound (US) was of no added value in determining remission in a randomized study of patients with rheumatoid arthritis (RA) who were managed with a treat-to-target (T2T) strategy, suggesting that it can be safely omitted for serial monitoring to assess remission. There was no difference in the probability of achieving sustained clinical remission and stopping radiographic progression between a strategy employing US and a conventional strategy (CS) based on clinical and laboratory assessments alone. These results from the randomized ARCTIC trial (NCT01205854) were presented at the 2015 annual meeting of the American College of Rheumatology.1
“The implementation and systematic use of US in the follow-up of early RA patients treated with an aggressive T2T strategy is not justified, based on these results,” concluded lead author Espen A. Haavardsholm, MD, Diakonhjemmet Hospital, Oslo, Norway.
US can detect subclinical inflammation, which is present in a large proportion of RA patients in clinical remission and is associated with radiographic progression and disease flare. With the use of US becoming more widespread in assessing RA joints, it is not clear that treating subclinical inflammation can improve long-term outcomes, and there is the possibility that it could lead to overtreatment. However, its use in this context is somewhat controversial, and some investigators believe US criteria should be part of the definition of remission.
ARCTIC was designed both to compare use of US assessment in a T2T strategy with targeted therapy aimed at imaging remission (complete absence of inflammation on US) versus a CS based on clinical and laboratory assessments alone as well as to determine whether US assessment would lead to improved clinical outcomes in RA.
The study enrolled 238 patients with early RA managed with a T2T strategy and randomized them to either US or CS. All patients were naive to disease-modifying antirheumatic drug therapy at the start of the study. Patients were followed in a tight control regimen with 13 visits over a 2-year follow-up period. The target for both treatment arms was disease activity score (DAS) <1.6, signifying clinical remission. Patients in the US arm were also treated to a target of no power Doppler signal in any joint.
The primary end point was the proportion of patients meeting all 3 of the following criteria: sustained clinical remission, defined as DAS <1.6 at 16, 20, and 24 months; no swollen joints at 16, 20, and 24 months; and no progression in van der Heijde–modified total Sharp score between 16 and 24 months. The primary end point was reached by 26 (22%) patients in the US group and 21 (18.8%) patients in the CS group, a nonsignificant difference. DAS scores were comparable during the 24-month study period. No statistically significant differences in radiographic joint damage were observed.
- Haavardsholm EA, Aga A-B, Olsen IC, et al. Aiming for remission in rheumatoid arthritis: clinical and radiographic outcomes from a randomized controlled strategy trial investigating the added value of ultrasonography in a treat-to-target regimen [abstract]. Arthritis Rheumatol. 2015;67(suppl 10). http://acrabstracts.org/abstract/aiming-for-remission-in-rheumatoid-arthritis-clinical-and-radiographic-outcomes-from-a-randomized-controlled-strategy-trial-investigating-the-added-value-of-ultrasonography-in-a-treat-to-target-regim/. Accessed November 30, 2015.