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Professor of Medicine and Population and Quantitative Health Sciences
Timothy S. and Elaine L. Peterson Chair in Rheumatology
Division of Rheumatology
Department of Medicine
University of Massachusetts Medical School
Division of Rheumatology
Department of Medicine
UMass Memorial Medical Center
Jonathan Kay, MD, has disclosed that he has received consulting fees from AbbVie, Boehringer Ingelheim, Celltrion, Jubilant Radiopharm, Pfizer, Samsung Bioepis, Sandoz, Scipher Medicine, and Union Chimique Belge and funds for research support from Gilead Sciences, Novartis, and Pfizer.
Vice Chair, Department of Medicine
Professor of Medicine, Microbiology and Immunology
The Geisel School of Medicine at Dartmouth
Lebanon, New Hampshire
William F. C. Rigby, MD, has disclosed that he has received funds for contracted research from AbbVie, Bristol-Myers Squibb, Gilead, and Lilly and consulting fees from AbbVie, Bristol-Myers Squibb, and Gilead.
William F. C. Rigby, MD:
Perhaps the greatest challenge in evaluating early rheumatoid arthritis (RA) is deciding the reliability of the history, physical exam, serology, and imaging in making the diagnosis and the need for disease-modifying antirheumatic drug (DMARD) therapy that may last a lifetime. In the absence of physical findings, what is the value of imaging such as ultrasound or MRI in identifying subclinical synovitis? Should you evaluate every patient with a positive rheumatoid serology to see if you are missing anything? And, if you find something should you initiate therapy?
These issues were addressed in a study by Rogier and colleagues at the 2020 virtual ACR/ARP Convergence. This study, performed in the Netherlands, took advantage of 3 cohorts of patients that had been evaluated for RA with imaging despite negative physical examinations. One patient cohort with symptoms of arthralgia was evaluated at baseline by MRI (162 patients), and 2 other cohorts (of 166 and 473 patients) were evaluated at baseline by musculoskeletal ultrasound. There were 3 years of follow-up in 2 cohorts and 1 year of follow-up on all 3.
At 1 year of follow-up, the percentage of patients who developed inflammatory arthritis was 22%, 15%, and 18% in the 3 cohorts. Subclinical synovitis was present in 36%, 41%, and 31% of participants. Approximately one half of the ACPA-positive patients (54%, 44%, and 68%) with subclinical synovitis on imaging did not develop inflammatory arthritis. In the absence of a positive ACPA serology, the absence of progression to inflammatory arthropathy occurred in more than two thirds of patients (66% to 89%). Similar differences were seen after 3 years of follow-up.
The conclusion of the authors was that false positivity, as defined by the absence of clinical synovitis with either positive ultrasound or MRI, had little predictive value at 3 years of follow-up. It is notable that many of these patients had a significant duration of symptoms ranging from 19-57 weeks, indicating chronicity. The authors concluded that the initiation of therapy (based on imaging instead of exam) had resulted in overtreatment with DMARDs.
The take-home message is that neither serology nor imaging is superior to the physical exam in making the diagnosis of RA and assessing the need for therapy. Our physical exam, without imaging, is sufficient to make the diagnosis of RA. By adding imaging with ultrasound or MRI, you can uncover more subclinical findings, but these are clinically meaningless and do not predict subsequent development of synovitis and need for therapy.
Implications for Telemedicine
The Rogier and colleagues study takes this finding in another direction when one considers the increasing application of telemedicine to the care of RA. For example, does a telemedicine phone call add anything for a patient being evaluated for RA? Moreover, if one uses a questionnaire rather than a physical exam, does the need for the exam go away? In fact, one could argue preclinical RA could be identified by telemedicine and a questionnaire just as easily as an in-person exam.
Can Patients With RA Examine Their Own Joints?
Jonathan Kay, MD:
The use of patient-reported joint counts to inform the management of RA was addressed by Benson and colleagues. These investigators assessed whether patients could reliably identify tender and swollen joint counts to calculate a clinical disease activity index (CDAI) that would indicate whether their disease was active or controlled.
They provided 460 patients with early RA (who were enrolled in either the Canadian CATCH or the United States CATCH-US cohort) with a homunculus diagram on which they were to indicate tenderness or swelling of 28 joints. The patients’ assessments were compared with those of rheumatologists who examined them.
Agreement between patient and rheumatologist joint counts was high and was greater when fewer joints were inflamed. They then calculated CDAI, which also incorporated patient and rheumatologist global assessments of disease activity. Any difference between the patient-derived CDAI and the rheumatologist-derived CDAI would result only from differences in tender and swollen joint counts, as both used the same global assessments of disease activity.
Since patient and rheumatologist joint counts differ most at the higher ends, one would expect greater discrepancies to occur in the moderate and high disease activity categories. This was observed in this study, with greater agreement between patient and rheumatologist CDAI classification of disease activity in lower categories of disease activity.
The authors concluded that self-assessment of a 28-joint count by patients with RA can distinguish between active and controlled RA. This approach could be applied to telemedicine when using a “treat-to-target” approach to the management of RA. However, further work is necessary to be able to implement use of patient-reported joint counts in telemedicine.
Can This Work in Practice?
In my practice, I find it more difficult to make a global assessment of a patient’s disease activity without seeing them in person. However, if patients were to provide me with their tender and swollen joint counts, I could make a reasonable global assessment of their disease activity by talking to them over a live audiovisual connection or even by telephone. There is a subjective component to the assessment of swollen and tender joints, even when performed by an experienced rheumatologist. Technologies in development, such as thermography, may someday be available for use in telemedicine to provide a more objective measurement of joint inflammation. We are entering a “brave new world.”
How is telemedicine influencing your practice? Answer the polling question and join the conversation by posting a comment in the discussion section. And for more from ACR/ARP 2020, download Capsule Summaries of all the key data.