Rheumatoid Arthritis: Keen HI

Keen HI, Lavie F, Wakefield RJ, D'Agostino MA, Hammer HB, Hensor E, Pendleton A, Kane D, Guerini H, Schueller-Weidekamm C, Kortekaas MC, Birrel F, Kloppenburg M, Stamm T, Watt I, Smolen JS, Maheu E, Dougados M, Conaghan PG. · Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, University of Leeds, Leeds, UK. · Ann Rheum Dis. · Pubmed #17704062 No free full text.

Abstract: OBJECTIVES: Painful osteoarthritis (OA) of the hand is common and a validated ultrasound (US) scoring system would be valuable for epidemiological and therapeutic outcome studies. US is increasingly used to assess peripheral joints, though most of the US focus in rheumatic diseases has been on rheumatoid arthritis. We aimed to develop a preliminary US hand OA scoring system, initially focusing on relevant pathological features with potentially high reliability. METHODS: A group of experts in the fields of OA, US and novel tool development agreed on domains and suggested scaling of the items to be used in US hand OA scoring systems. A multi-observer reliability exercise was then performed to evaluate the draft items. RESULTS: Synovitis (grey scale and Power Doppler) and osteophytes (representing activity and damage domains) were included and evaluated as the initial components of the scoring system. All three features were evaluated for their presence/absence and if present were scored using a 1-3 scale. The reliability exercise demonstrated intra-reader kappa values of 0.444-1.0, 0.211-1.0 and 0.087-1.0 for grey scale synovitis, power Doppler and osteophytes respectively. Inter-reader reliability kappa values were 0.398, 0.327 and 0.530 grey-scale synovitis, power Doppler and osteophytes respectively. Without extensive standardisation, both intra- and inter-reader reliability were moderately good. CONCLUSIONS: The draft scoring system demonstrated substantive to almost perfect percentage exact agreement on the presence/absence of the selected OA features and moderate to substantive percentage exact agreement on semi-quantitative grading. This preliminary process provides a good basis from which to further develop an US outcome tool for hand OA that has the potential to be utilised in multicentre clinical trials.

Keen HI, Brown AK, Wakefield RJ, Conaghan PG. · Academic Unit of Musculoskeletal Disease, Department of Rheumatology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. · Rheum Dis Clin North Am. · Pubmed #16287592 No free full text.

Abstract: Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium and is characterized by destruction of bone and cartilage. Early diagnosis and treatment of RA can improve disease outcomes substantially. Magnetic resonance imaging and musculoskeletal ultrasonography may facilitate early diagnosis and aid the targeting of intensive therapy. Magnetic resonance imaging and musculoskeletal ultrasonography also are able to monitor temporal changes in disease activity (ie, synovitis) and damage (ie, erosions). These imaging modalities are likely to be increasingly used in the management of early rheumatoid arthritis to ensure the best patient outcomes, although more work is required to determine their optimal roles.

Keen HI, Emery P. · Academic Unit of Musculoskeletal Disease, Department of Rheumatology, Leeds General Infirmary, Leeds, UK. · Curr Opin Rheumatol. · Pubmed #15838237 No free full text.

Abstract: PURPOSE OF REVIEW: Rheumatoid arthritis is a chronic systemic and progressive inflammatory disorder of the synovium characterised by destruction of bone and cartilage. It is associated with significant morbidity and economic costs. Recent advances have shown that early diagnosis and timely, intensive therapy of rheumatoid arthritis can modify disease outcomes. RECENT FINDINGS: Current investigations into the role of ultrasonography and magnetic resonance imaging in early rheumatoid arthritis suggest these modalities will provide information to assist in the early diagnosis of rheumatoid arthritis, identify poor prognostic factors, and aid in the monitoring of response to therapy. New developments in pharmacologic therapy, particularly the development of biologic agents, allow better disease control than was previously achievable, and the early application of these drugs in combination with conventional disease-modifying antirheumatic drugs seems to produce the best outcomes. SUMMARY: The application of novel imaging techniques will aid the target application of biologic therapy within the window of opportunity and aid in the monitoring of response to therapy. This is likely to significantly decrease the rate of structural damage and offers hope of a future when the normal outcome for rheumatoid arthritis will be remission.

Proudman SM, Keen HI, Stamp LK, Lee AT, Goldblatt F, Ayres OC, Rischmueller M, James MJ, Hill CL, Caughey GE, Cleland LG. · Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia. · Semin Arthritis Rheum. · Pubmed #17391739 No free full text.

Abstract: OBJECTIVES: To assess the safety and efficacy of combination therapy in recent-onset rheumatoid arthritis (RA), with dose adjustments determined by response, in a clinic setting over 3 years. METHODS: Disease-modifying antirheumatic drug (DMARD)-naive patients with RA of median duration of 12 weeks (n = 61) attending an early arthritis clinic were treated with methotrexate, sulfasalazine, hydroxychloroquine, and fish oil. Dosage adjustments and additions of further DMARDs were contingent on response to therapy and tolerance. Outcome measures for efficacy were Disease Activity Score (DAS28), clinical remission, and modified Sharp radiographic score and for safety, adverse events, and DMARD withdrawal. RESULTS: At baseline, subjects had at least moderately active disease (mean +/- SD DAS28 was 5.3 +/- 1.1), impaired function as measured by the modified Health Assessment Questionnaire (mHAQ) (0.9 +/- 0.5), and 37% had bone erosions. By 3 months, 29% were in remission; this increased to 54% at 3 years. The greatest fall in DAS28 and improvement in mHAQ scores occurred in the first 12 months. Erosions were detected in 62% at 3 years. The mean dose of parenteral glucocorticoid was equivalent to 0.1 mg/d of prednisolone. After 3 years, 48% remained on triple therapy; fish oil was consumed by 75% of patients, and 21% used nonsteroidal anti-inflammatory drugs. Gastrointestinal intolerance was the most frequent unwanted event (leading to DMARD withdrawal in 17 patients). Sulfasalazine was most frequently withdrawn (30%). CONCLUSION: This implementation study demonstrates the feasibility, safety, and efficacy of combination therapy with inexpensive DMARDs, fish oil, and minimal glucocorticoid use, in routine clinical practice using predefined rules for dosage adjustment.