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In-office imaging in the care of patients with rheumatoid arthritis

Nature Clinical Practice Rheumatology volume 1, pages 64–65 (2005)Cite this article

Erosion scoring and joint-space narrowing have demonstrated that multiple agents slow radiographic progression in rheumatoid arthritis (RA).1,2,3,4,5 Translating data from treatment groups in clinical trials to the individual patient, however, is a difficult task for clinicians. Depiction of radiographic data in a cumulative frequency plot6 helps by clarifying that most patients in clinical trials have no radiographic progression. Some patients have negative progression scores, representing either scoring errors or repair of erosions and, very questionably, repair of cartilage. Other patients have positive progression scores (because of error, or increasing size and number of erosions) or greater joint-space narrowing, or both. With every patient visit, therefore, the practitioner is faced with the question of which group the patient belongs to.

There are many possible approaches to finding the answer. Are INTERVAL X-RAY FILM EVALUATIONS an option; and if so, at what interval should they be used? Will MRI suffice or even help? What about DOPPLER ULTRASOUND (DUS)? Plain radiographic examination gives retrospective information. Any progression of joint damage attributable to the disease is a clear indication that the disease has been active during part of, or throughout, the interval between films. The recent claim that radiographic progression occurred while patients met criteria for remission is almost certainly attributable to faulty criteria for remission.7,8 Most rheumatology training programs include experience in interpreting radiographs and most rheumatologists learn to distinguish artefactual changes produced by technical problems from real erosions, so that plain film radiographic images taken using standardized procedures of positioning, exposure and development of films are accurately interpreted when sizeable new erosions appear or pre-existing erosions grossly enlarge. It is the borderline case (i.e. the presentation of a small change in the erosion or joint-space width in films that are slightly rotated or taken with a different X-ray exposure or film development) that poses a dilemma for physician and patient. The question that arises is what is the fail-safe prescription for a patient in this case? Should the physician switch medication, add another therapeutic agent to the existing regime, refrain from intervention and get more films in 3 months, 6 months or 1 year, or perform MRI or DUS? If the patient is already receiving the most effective treatment available and the putative new therapy 'on the verge of introduction' has little record of efficacy, and perhaps even less record of safety, refraining from further intervention is often the best answer. In the case of the patient with further feasible options in terms of prescribing a new therapy, either by adding on or switching to a therapeutic agent not previously used, the clinician's choice is whether to change therapy without further imaging or to obtain new 'baseline' MRI or DUS images before proceeding with new therapy.

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  1. Affiliate Clinical Professor of Medicine in the Department of Medicine, Rheumatology Division at the University of Washington School of Medicine, Seattle, WA, USA

    John T Sharp

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  1. John T Sharp
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Correspondence to John T Sharp.

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Sharp, J. In-office imaging in the care of patients with rheumatoid arthritis. Nat Rev Rheumatol 1, 64–65 (2005). https://doi.org/10.1038/ncprheum0051

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