“Rheumatism” is a popular term encapsulating a whole range of different ailments, some of which are associated with inflammation of the joints. The most common of these inflammatory rheumatic diseases is rheumatoid arthritis, which affects between a half and one percent of the total population. Unlike arthrosis of the finger joints, a widespread disorder, rheumatoid arthritis is not due to wear and tear in the joint, but to a disorder of the immune system, which begins to attack the body’s own structures and especially joints. This disease not only affects older people, but frequently occurs in middle age, sometimes even in young adults and children. The exact cause is not completely clear.
Current treatment involves drugs that influence the immune system and is based on the recommendations of the European League Against Rheumatism EULAR. Doctors regularly evaluate the healing progress and adapt their therapy continuously. It was shown that, if the patient’s response is favourable, certain drugs can be discontinued without having to anticipate a renewed deterioration. However, the right criteria for discontinuing medication have yet to be defined, and in certain cases relapses do occur. A research group headed by principal investigator Christian Dejaco from the Medical University of Graz is now conducting a clinical study to investigate the extent to which ultrasound examinations of the joints can generate appropriate criteria for deciding whether the patient should stop taking medication.
Drugs of biotech origin
“With rheumatoid arthritis, it is important to make the diagnosis early on,” explains Christian Dejaco. “In an early phase of the disease there is a time window in which there is a particularly good chance of making a lasting positive impact.” The therapy involves drugs. In addition to cortisone and various so-called conventional basic therapies, a number of relatively new drugs of biotechnological origin, known as biopharmaceuticals or biologics, are used. These biologics intervene in certain processes of the human immune response. “The goal is to achieve low-level disease activity or full remission,” says Dejaco.
“In this context, remission is understood to mean the disappearance of any clinical manifestation of the disease.” According to the physician, it is not yet fully clear at what point discontinuing the biologics can be considered: “It is known that a certain percentage of those affected experience a recurrence of the disease within about half a year. With the present study we are trying to answer the question as to whether ultrasonography can be used to identify a group of patients who will remain in remission after discontinuing the biologics therapy.”
Ultrasonography is a relatively easy way for doctors to view the inside of joints. Past research has identified factors by which the effects of rheumatoid arthritis in joints can be detected in ultrasound images. These factors include thickening of the joint membrane or the presence of fluid in the joint. It is also possible to visualise the blood flow in the joint membrane. “A strong blood supply to the joint membrane carries with it a high level of inflammation,” explains the physician. It is striking that the results of ultrasound examinations often do not match the clinical assessment, notes Dejaco: “There are patients who appear to be in remission upon a medical examination whereas the ultrasound still shows disease activity, and vice versa. Past studies have shown that patients who are in remission according to clinical assessment, but still show traces of the disease in ultrasound, have a higher risk of disease flares.” This observation was the basis for Dejaco’s hypothesis for the new study.
The study intends to observe 110 people in remission – i.e. people in whom rheumatoid arthritis has come to a standstill according to clinical assessment – over a period of several months. Dejaco explains that the special distinction here as compared to previous studies is twofold: the size of the group investigated and the precise definition of remission. The latter renders the selection of study participants particularly stringent. One group of people has already been studied or is under observation, others are still being recruited. As soon as recruitment is completed, the evaluations will begin.
Upgrading the importance of ultrasonography
If the study is successful, ultrasound could become more important in the assessment of patients with rheumatoid arthritis. Dejaco emphasizes that ultrasound examination is not standard in this field: “Many rheumatologists do not use ultrasound or use it only sporadically, and many do not perform the examination themselves.” In principle, however, an ultrasound examination could be carried out easily and quickly in the examination room, as Dejaco notes. In the future, ultrasound could help to reduce the use of drugs in the therapy of rheumatoid arthritis, with positive effects for patients and the health care system.
Christian Dejaco is an associate professor at the Medical University of Graz and head physician of the rheumatological service of the North Italian province of Trentino-Alto Adige. He conducts research and works in the fields of rheumatology and immunology. With support of the FWF the clinical research project “Ultrasound-based withdrawal of biologics in rheumatoid arthritis” will continue until 2021.