Regular use of ultrasound may lead to more intensive treatment, but does not significantly affect short-term outcomes.

INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints and sometimes their internal organs. Many studies have suggested that treatment and interventions should target disease in the early stages to help prevent disability and long-term damage. Current treatment recommendations suggest that disease-modifying antirheumatic drugs (DMARDs) should be used early as part of a ‘treat-to-target’ strategy to achieve low disease activity or remission. Imaging techniques allow doctors to see inside the joints to assess any damage and to monitor disease activity and progression (worsening). Common imaging techniques include X-ray, magnetic resonance imaging (MRI) and ultrasound. Musculoskeletal ultrasound is useful for assessing disease activity in rheumatoid arthritis because it is easy and convenient to use, it avoids the use of radiation, and it allows multiple joints and areas to be examined during a single appointment. This allows clinical flares and the progression or worsening of joint damage to be predicted.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to see whether the outcomes for people with rheumatoid arthritis could be improved by adding a musculoskeletal ultrasound assessment to an intensive early treatment strategy.

WHO WAS STUDIED?
The study took place at three clinics in Scotland between 2009 and 2013. It looked at 111 people who had recently been diagnosed with either rheumatoid arthritis or undifferentiated inflammatory arthritis, defined as having more than three swollen joints and testing positive for anti-CCP antibodies in their blood. Patients with anti-CCP antibodies tend to have rheumatoid arthritis, though not all patients with rheumatoid arthritis have these antibodies. All people included in the study were over the age of 18 and their symptoms had lasted longer than 12 months.

HOW WAS THE STUDY CONDUCTED?
This was an open-label, randomised control trial, which means that patients were assigned by chance to one of two treatment groups. Using chance in this way means that the groups will be similar and will allow the variable or treatment under investigation to be compared objectively. The groups were matched based on clinical, demographic and radiographic characteristics. The first group of people (the control group) had their DMARD doses increased based on their doctor’s clinical assessment of their joints and certain markers in their blood called rheumatoid factor and ESR. Rheumatoid factor is a protein found in the blood of 80% of adults with rheumatoid arthritis. ESR is a test to measure how quickly red blood cells fall to the bottom of a tube. A faster rate indicates the presence of inflammation. It is sometimes called the ‘sed rate’ for short. The ESR is one of the most widely used laboratory tests to assess inflammation in rheumatoid arthritis. The second group of people (the intervention group) had their dose decisions made based on the doctor’s clinical assessment, plus an ultrasound. During the treatment both patients and their doctors knew which group they were in. The people in the study were then checked every 3 months to see how well they were doing. X-rays and MRIs were performed at the start of the study and after 18 months.

WHAT WERE THE MAIN FINDINGS OF THE STUDY?
Both groups had significant improvements in their disease over the course of the study. The X-rays and MRIs taken showed that there was not much damage in the joints over that period in either group. Using musculoskeletal ultrasound to guide treatment decisions meant that people in the intervention group received more intensive therapy such as more combinations of drugs, or earlier use of biologic therapies. However, the overall outcomes in terms of achieving disease activity or remission were no different to the people in the control group.

ARE THESE FINDINGS NEW?
The effectiveness of intensive treat-to-target strategies has been well established. But this is the first time that the impact of adding musculoskeletal ultrasound assessment to this type of treatment approach has been investigated.

WHAT ARE THE LIMITATIONS OF THE STUDY?
The study period may have been too short, and the main clinical outcome measures may not have been sensitive enough to demonstrate a clear difference between the two groups.

WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The study findings have been presented at clinical meetings and are being shared with other doctors. The study is ongoing to collect outcomes over 5 years, which may demonstrate if there is a difference in the two treatment groups’ outcomes over a longer time period.

WHAT DOES THIS MEAN FOR ME?
These results reinforce that prompt and intensive early treatment in people with newly diagnosed rheumatoid arthritis can give significant improvements in disease activity and function and minimise joint damage progression. They also suggest that it may not be necessary to spend additional consultation time performing musculoskeletal ultrasound examinations in people who have few symptoms. If you have rheumatoid arthritis, this could mean that your consultation times will be shorter and that your rheumatologist will be able to see more patients in a single clinic.

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Date prepared: June 2016

Summary based on research article published on: 29 March 2016

From: Dale J, et al. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis 2016;75:1043–50. doi:10.1136/annrheumdis-2015-208941 Copyright © 2016 BMJ Publishing Group Ltd & European League Against Rheumatism. Medical professionals may print copies for their and their patients and students non commercial use. Other individuals may print a single copy for their personal, non commercial use. For other uses please contact our Rights and Licensing Team.

FURTHER READING
Smolen JS, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 2016;75:3–15. doi: 10.1136/annrheumdis-2015-207524. A lay summary of this article is available at: http://ard.bmj.com/content/suppl/2016/03/08/ annrheumdis-2015-207524.DC2/annrheumdis-2015-207524supp_Laysummary.pdf