MRI-guided treatment strategy unnecessary for RA in clinical remission
medwireNews: A magnetic resonance imaging (MRI)-guided treat-to-target strategy does not improve disease activity or slow joint damage progression compared with a conventional strategy in patients with rheumatoid arthritis (RA) in clinical remission, research shows.
The IMAGINE-RA trial included 100 patients with RA in clinical remission, according to a Disease Activity Score at 28 joints based on C-reactive protein (DAS28-CRP) of below 3.2 and no swollen joints. They were randomly assigned to an MRI-guided treat-to-target strategy with the aim of achieving an absence of MRI bone marrow oedema combined with clinical remission as per the criteria for trial inclusion.
A further 100 patients were assigned to a conventional treat-to-target strategy in which the treatment goal was clinical remission only.
In both groups, patients were assessed every 4 months and treatment was escalated according to a predefined algorithm if the target was not reached.
At 2 years, 85% of 76 patients who completed the study in the MRI-guided group reached the primary clinical endpoint of remission (DAS28-CRP <2.6), while 66% met the primary radiographic endpoint of no increase in total van der Heijde–modified Sharp score.
The corresponding proportions among the 95 patients who completed the study in the conventional group were 88% and 62%, with no significant difference between the two strategies.
Writing in JAMA, Signe Møller-Bisgaard (Copenhagen Center for Arthritis Research, Denmark) and co-investigators say that “[t]hese findings do not support the use of an MRI-guided strategy for treating patients with RA.”
They also note that a higher proportion of patients in the MRI-group than in the conventional group had treatment escalations (73 vs 17%), received biological treatment (46 vs 2%), experienced serious adverse events (17% vs 6%) and discontinued therapy (24 vs 5%).
Daniel Aletaha and Josef Smolen, both from the Medical University of Vienna in Austria, write in an editorial that accompanies the study that “[a]ltogether, the use of imaging to guide therapy in RA did not meet the criteria for ‘rational use of medicines’ as defined by the World Health Organization because using imaging to guide therapy led to prescription of potentially harmful medicines without differences in the primary outcomes, but at high costs and potential burden of unnecessary treatment changes and risks for patients.”
But they believe that sonography and MRI are still important in RA, pointing out that these techniques “are excellent diagnostic tools that should be used to evaluate symptoms and confirm diagnoses in joints that are difficult to examine clinically, such as the shoulder or foot joints or in tendon sheaths.”
The editorialists conclude, however, that “these uses of imaging are diagnostic, rather than guiding treatment.”
By Laura Cowen
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