RESEARCH - Disease remission state in patients treated with TNF blockade + MTX or with DMARDs

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Arthritis Rheum. 2009 Jul;60(7):1915-22.

Disease remission state in patients treated with the combination of

tumor necrosis factor blockade and methotrexate or with

disease-modifying antirheumatic drugs: A clinical and imaging

comparative study.

Saleem B, Brown AK, Keen H, Nizam S, Freeston J, Karim Z, Quinn M,

Wakefield R, Hensor E, Conaghan PG, Emery P.

University of Leeds, Chapel Allerton Hospital, Leeds, UK.

OBJECTIVE: For patients with rheumatoid arthritis (RA) in remission

who are receiving disease-modifying antirheumatic drugs (DMARDs),

radiographic progression correlates with imaging-detected synovitis as

measured by power Doppler activity. In contrast, patients with disease

in remission who are receiving the combination of tumor necrosis

factor (TNF) blockade with methotrexate (MTX) (combination treatment)

have reduced radiographic damage for the equivalent clinical state. We

undertook this study to determine whether the difference in

radiographic outcome is a result of more complete suppression of

imaging-detected synovitis.

METHODS: One hundred patients with RA in remission (Disease Activity

Score in 28 joints [DAS28] <2.6) for at least 6 months while receiving

either combination treatment (n = 50) or DMARDs (n = 50) were matched

for clinical variables. Ultrasound of metacarpophalangeal joints 1-5

and the wrist joints was performed. Remission according to imaging

results was defined as a score of 0 for both grey scale synovitis and

power Doppler activity.

RESULTS: In patients receiving combination treatment or DMARDs (median

DAS28 1.65 versus 1.78, median disease duration 120 months versus 90

months, and median duration of remission 13 months versus 18 months),

the proportion with remission according to imaging results was not

significantly different (10% versus 16%, respectively). The

combination treatment group had more grey scale synovitis (P < 0.001)

but similar power Doppler activity (48% versus 60%, respectively; P =

0.229) in any joint as compared with the DMARD group. Results were not

affected by stratification for duration of disease or remission.

CONCLUSION: In RA patients with disease in remission, imaging-detected

synovitis persists, with power Doppler activity seen in >or=48% of the

patients regardless of therapy. These results suggest that superior

radiographic outcomes in patients treated with the combination of TNF

blockade and MTX may not be due to complete suppression of

imaging-detected synovitis.

PMID: 19565512

http://www.ncbi.nlm.nih.gov/pubmed/19565512

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