MRI-guided treat-to-target strategy in RA patients in remission not superior to conventional treat-to-target strategy

Using MRI-guided treat-to-target strategy did not improve the rate of disease activity or reduce radiographic progression compared with a conventional treat-to-target strategy in patients with rheumatoid arthritis in clinical remission, reports a new JAMA study, online Feb. 5, 2019.

The 2-year multicenter IMAGINE-RA trial randomized patients with RA in clinical remission, to either MRI-guided treat-to-target strategy or conventional treat-to-target strategy. Results showed that 85% vs 88%, respectively, reached the primary clinical end point (absence of MRI bone marrow edema combined with clinical remission, defined as DAS28-CRP <3.2 with no swollen joints). And, 66% vs 62%, respectively, reached the primary radiographic end point (patients with no radiographic progression) at the end of the study.

These differences are statistically non-significant suggesting no added benefit of the MRI-guided approach in these patients.

Based on their findings, the authors do not recommend use of an MRI-guided treat-to-target strategy for patients with RA in clinical remission.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Emedinews: Dr Good Dr Bad: A patient with rheumatoid arthritis was to be put on Leflunomide.

Situation: A patient with rheumatoid arthritis was to be put on Leflunomide. 

Dr. Bad: Go ahead.
Dr. Good: Avoid it.
Lesson: Exposure to leflunomide, embryotoxic and teratogenic, must be avoided during pregnancy.
(Arthritis Rheum 2010;62:1494)

#AskDrKK: When to give intra-articular steroid injections?

#DrKKAnswers: They can be given for one or a few joints if infection has been excluded. Oral glucocorticoids should be avoided or used in low dose.

#AskDrKK:What else can be tried in the treatment?

#DrKKAnswers: Additional therapies may include simple analgesics (paracetamol), bisphosphonates, nutritional supplements and cardiovascular risk reduction strategies.

#AskDrKK: Which is the first line DMRD’s in early and mild rheumatoid arthritis?

#DrKKAnswers: Hydroxychloroquine or sulfasalazine because of their relative safety.

#AskDrKK: When to start DMRD in early and mild rheumatoid arthritis?

#DrKKAnswers: Disease modifying antirheumatic drugs should be started in all patients whose disease does not remit after six weeks to three months of treatment with NSAIDs alone. 

#AskDrKK: What is the initial treatment of a patient with early and mild rheumatoid arthritis?

#DrKKAnswers: Initial therapy of patients with mild disease includes an NSAID at full therapeutic dose, unless contraindicated.

#AskDrKK: In mild rheumatoid arthritis can anti CCP antibodies be negative?

#DrKKAnswers: Absence of rheumatoid factor or antibodies to cyclic citrullinated peptides is a favorable prognostic factor.

#AskDrKK: Can mild rheumatoid arthritis be seropositive?

#DrKKAnswers: A patient need not be "seronegative" to be categorized as having mild disease.

#AskDrKK: What is early and mild rheumatoid arthritis?

#DrKKAnswers: Patients have disease of less than six months duration who meet the ACR criteria for RA and typically have less than six inflamed joints, no extraarticular disease, and no evidence of erosions or cartilage loss on plain radiographs. 

AskDrKK: Can Methotrexate cause fevr when combined with azathioprine?

Dr KK Answers: Fever is recognized when certain drugs are used in combination, such as methotrexate and azathioprine in the treatment of refractory rheumatoid arthritis.