Additional Algorithms Developed to Guide Ultrasound Use in RA

A panel of experts was assembled to develop specific guidance on the use of ultrasound in RA treatment.

Algorithms for practical application of ultrasound in diagnosis and treatment of rheumatoid arthritis (RA) should be developed and implemented in clinical practice, according to research published in the Annals of Rheumatic Disease.

Maria Antionetta D’Agostino, MD, PhD, Hôpital Ambroise Paré, Boulogne-Billancourt, France, and the Leeds Institute of Rheumatic and Musculoskeletal Medicine,Leeds University, UK, and colleagues set out to provide guidance—supplemental to current European League against Rheumatism (EULAR) imaging recommendations—for the use of ultrasound in the diagnosis and management of RA

“Among the different imaging techniques, ultrasound has shown to be of particular help in the diagnostic workup of RA, in guiding treatment decisions, and in monitoring disease activity and remission,” wrote Dr D’Agostino and colleagues. “Although EULAR recommendations and published data support the use of ultrasound in several areas of RA management, they do not provide specific guidance on how to use ultrasound, which may result in an inconsistent or suboptimal utilization…and potentially the suboptimal treatment of patients.”

The researchers followed a 2-step procedure to develop the ultrasound guidance recommendations. First, an expert group of 10 experienced rheumatologists from 7 European countries met twice in September 2014 and January 2015. These meetings had the following objectives:

  1. To formulate key clinical questions related to the use of ultrasound in RA
  2. To identify and critically appraise available evidence
  3. To generate pragmatic algorithms on the application of ultrasound in suspected or established RA

The group was divided into 3 task forces, each of whom analyzed a selection of literature to answer the following questions:

  1. The role of ultrasound for improving the diagnosis of RA
  2. The role of ultrasound for monitoring response to treatment
  3. The role of ultrasound in evaluating subclinical disease activity in stable disease states

The expert panel proposed 3 potential uses of ultrasound during the diagnostic workup. First, to determine whether subclinical synovitis is present in at-risk patients with no sign of inflammation (Figure 1). Second, to reassess patients whose clinical synovitis does not fulfill ACR/EULAR criteria (Figure 2).  Third to confirm the diagnosis in patients who fulfill the ACR/EULAR criteria but doubt exists that diagnosis may be a false positive. 

Additionally, both literature review and expert opinion suggests that patients with RA undergoing treatment with either conventional synthetic DMARDs (csDMARDs) or biologic DMARDs (bDMARDs) should undergo ultrasound assessment at baseline and after 3 to 6 months of treatment to assess treatment response.

“Developments in the management of RA in recent years have produced remarkable improvements in patient outcomes,” Dr D’Agostino and colleagues concluded. “It is important that imaging techniques keep pace with these advancements.”  

 ACPA = anti–citrullinated protein antibody; ACR = American College of Rheumatology; EULAR = European League Against Rheumatism; RA = rheumatoid arthritis; RF = rheumatoid factor;  US = ultrasound

ACR = American College of Rheumatology; EULAR = European League Against Rheumatism; RA = rheumatoid arthritis; US = ultrasound

Click figures to enlarge. 

Summary and Clinical Applicability

The algorithmic approach described by researchers provides a way for clinicians to provide targeted US assessments of patients with RA. 


AbbVie provided an independent grant to the University of Leeds to support the development of the paper by Dr D’Agostino et al. The authors of this paper are members of the independent TUI Steering Committee, which previously received support from AbbVie.

Dr Emery has undertaken clinical trials and provided expert support to Pfizer, MSD, AbbVie, MBS, UCB, Roche, Novartis, Samsung, Sandoz, and Lilly. Dr D’Agostino has received speaker bureau from MSD, AbbVie, BMS, UCB, Roche, and Novartis. 

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D’Agostino MA, Terslev L, Wakefield R, et al. Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission. Ann Rheum Dis. 2016 Aug 23 doi: 10.1136/annrheumdis-2016-209646 [Epub ahead of print]

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