MRI shows ongoing inflammation despite clinical remission in early RA

Two years of either triple therapy or treatment with tumor necrosis factor plus methotrexate failed to eliminate joint inflammation on MRI in a subcohort of patients with early rheumatoid arthritis from the randomized, double-blind Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial.

In 118 patients with a mean age of 51 years, short disease duration, and severe disease at TEAR trial entry – 92% of whom were seropositive – only 29 had wrist pain, tenderness, or swelling at 2-year follow-up. However, all 118 patients had MRI evidence of residual joint inflammation after 2 years, and 78% had evidence of osteitis, Dr. Veena K. Ranganath of the University of California, Los Angeles, and her colleagues reported (Arthritis Care Res. 2015 Jan. 7 [doi:10.1002/acr.22541]).

Dr. Veena K. Ranganath

Inflammation remained despite significant improvement of disease activity measures at the time of the MRI, compared with baseline (for example, 28-joint disease activity score using erythrocyte sedimentation rate [DAS28-ESR] decreased from 5.8 to 2.9). Total MRI inflammation scores were significantly lower in patients who met 2011 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission criteria and remission by Chronic Disease Activity Index (CDAI), but not in those with DAS28-ESR remission, they noted.

The findings demonstrate that total MRI inflammatory scores are “best differentiated by the most stringent clinical remission criteria” – CDAI and 2011 ACR/EULAR Boolean Criteria, as opposed to DAS28-ESR (with a 2.6 cutpoint). Further, no differences were seen in damage or MRI inflammatory scores based on treatment regimen, which supports methotrexate-first recommendations for the TEAR trial, they said, noting that the long-term prognostic implications of the study findings are unclear because of short-follow-up, and that it remains unclear whether attainment of clinical remission warrants a drug holiday or cessation of RA treatment.

Thus, it is “ill-advised to discontinue therapy until future studies suggest otherwise,” they concluded, adding that this is particularly true given that prior published data suggest a link between osteitis – which occurred at a high rate in this study despite clinical remission – and future radiographic progression.

The TEAR trial was supported by Amgen. The current research was supported by a National Institutes of Health/National Center for Advancing Translational Science UCLA CTSI grant, and individual authors were supported by ACR/REF grants, a National Institutes of Health award, the Margaret J. Miller Endowed Professor of Research Chair, and the Agency for Healthcare Research and Quality.