Ep 28. Does ultrasound-defined tenosynovitis and synovitis aid the prediction of persistent arthritis?

Dr Ilfita Sahbudin joins Dr Marwan Bukhari to discuss the value of ultrasound-defined tenosynovitis and synovitis in the prediction of persistent arthritis in an inception cohort of DMARD-naive patients with early arthritis. Listen now to hear the results of a study involving one hundred and fifty DMARD-naïve patients and the implications for future clinical practice!

You can read this article [https://doi.org/10.1093/rheumatology/keac199] in Rheumatology.

Keywords: early arthritis, ultrasound, prediction, persistent arthritis

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Transcript

Voiceover 0:01 You're listening to the Talking Rheumatology Research podcast brought to you by the British Society for Rheumatology.  

Marwan Bukhari 0:14 Hi, good day. My name is Marwan Bukhari, I'm the Editor-in-Chief of Rheumatology and we're talking about ultrasound today. I'm a rheumatologist from the northwest of England, and we've got some distinguished guests from Birmingham talking to us today about the importance of ultrasound. So Ilfita, can you introduce yourself and tell us a bit about you? 

Ilfita Sahbudin 0:32 Hello, thank you for inviting me for this podcast today. I'm Ilfita Sahbudin, honorary consultant rheumatologist. Currently, I'm based at the Rheumatology Research Group at the University of Birmingham. 

Marwan Bukhari 0:43 Okay, so tell me a bit more about your research. So you're talking about ultrasound, so what what have you done? 

Ilfita Sahbudin 0:49 So basically, what we've done is, this is a large cohort study we've been running over the last 20 years. And specifically, my research study looks at how we can use ultrasound best in clinical practice. Because currently, although some rheumatologists are using them in a clinical practice, there is currently no validation in the prediction algorithm which includes imaging, and specifically, I'm really interested in looking at the tendon ultrasound because you and I know that it's almost impossible to examine tendon inflammation. We're really good at joint inflammation, but tendon inflammation is very tricky. So that's what my research comes in. 

Marwan Bukhari 1:31 Okay, so what did the study show? How did you choose your patients and what happened? 

Ilfita Sahbudin 1:36 So we choose patients when they are recruited into the Birmingham Early Arthritis Cohort, the BEACON cohort. They have to be newly diagnosed and with symptom duration of less than three months, and they must not take any medication. So all of our patients are DMARD naive. And what we do at baseline is we collect the standard, or if you like, conventional variables, so that would be the rheumatoid factor, inflammatory markers, joint count. We also perform ultrasound. So we scan all of the small joints of the hands as well as the tendon. So this is the novelty bit of our study. We then follow up the patient for 18 months. So at 18 months, the patients are split into two groups. So one group have persistent arthritis, for which the majority is rheumatoid arthritis, the others are psoriatic and other types of arthritis which require treatment. And the remaining patients, another third of the patients, would have resolving arthritis. So these are patients who do not have any joint swelling, and did not require any DMARDs or steroid over the last three months prior to the last group. So the idea is ultrasound, we use it as a prediction tool, or a crystal ball if you like. So what we noticed is that those patients who have ultrasound tendon inflammation markers at baseline, they have a very high predictive value of developing persistent arthritis at 18 months. 

Marwan Bukhari 3:02 Okay, so when you look at it, so the ARCTIC trial, for example, was a very much controversial trial that said ultrasound isn't important. So what would the rheumatologist take from this? You know, should you take everybody who comes into your clinic with suspected inflammatory arthritis and scan them and look at the tendon rather than looking at the joint? 

Ilfita Sahbudin 3:24 So basically, what our study shows is that tendon ultrasound has independent predictive value, meaning that in patients where they are already rheumatoid factor positive, and they have positive joint ultrasound. However, if you scan the tendon, that's an additional risk factor of developing persistent arthritis. So in terms of the ARCTIC study, just to mention, so that's, that's a study looking at treat-to-target, which is a completely different question from what I'm asking in my research study, which is 'what is the predictive value of tendon ultrasound at baseline?' So as rheumatologists what I would say is you have a scanner in your in your clinic room - apart from scanning the MCP, PIP and MTP joints, you should scan the digit flexor tendon. So we all have a 10 digit flexor tendons, which one do we scan? At the moment we would say scan all of them apart from the thumb. But the next part of our study is about understanding, collecting more data to understand which of the 10 digit flexors has the maximum predictive value, because then we can cut down the scanning time. 

Marwan Bukhari 4:34 That's exactly my next question. Because if you've still got eight flexor tendons, that's quite a lot of tendons to do. Now people talk about the ultrasound six, people talk about the ultrasound, n number of joints that you do. So you measure the index and middle finger and the fifth metatarsal - if it's not there, it's not going to give you any more information. How would a clinical rheumatologist take this and say, I want to just do a limited number of scans to give me the maximum amount of output? 

Ilfita Sahbudin 5:04 Yes, that's a very good question. So I would say scan the symptomatic joints which are not swollen. So basically, if the patient is very stiff but you can't see much in the way of joint swelling, think "Is there any tendon inflammation?", because that's an early marker of disease development. 

Marwan Bukhari 5:27 Okay, that's brilliant. So that's something that a rheumatologist will take: if it's tender, scan it, you might get more information and look at the inflammation in the tendons more than anything else. Because we don't measure flexor problems, we don't measure tendon synovitis. It's nothing that happens in the DAS28 or any other disease activity measure. So do you think that maybe ultrasound will be the answer to looking at inflammation that is not in the joint? 

Ilfita Sahbudin 5:56 Absolutely, absolutely. I mean, obviously, if you want to challenge me in terms of, "Oh, why can't I do MRI?", of course you can do MRI. But then you need to inject the dye, it costs more to the NHS, there's a waiting list. Plus, if there are more contraindications, such as a pacemaker. And one thing with highlighting is that patients who are seronegative rheumatoid arthritis or seronegative inflammatory arthritis, they still show that at baseline this tendon ultrasound is quite specific in the prediction of persistent arthritis. And this is fantastic because you and I know that patients with seronegative rheumatoid factor and ACPA... sometimes it's a bit tricky to diagnose because they don't have the autoantibodies. So then this is an additional predictive marker, which you can do in clinic, it take five seconds to scan a couple of tendons, you know about half a minute if you want to scan 10 tendons. So it then is a really useful predictive marker. So I really feel strongly about the fact that rheumatologists should scan tendons if they think about scanning patients in early arthritis clinic. 

Marwan Bukhari 7:07 I would probably argue as an amateur sonographer, that it will take me a lot longer than seconds to scan somebody's flexor tendons, but that's something that we would take. So what's the next step? What are you going to do further on with your research?  

Ilfita Sahbudin 7:19 So basically, we're scanning more patients in the larger cohort, because we'd like to come up with a predictive scoring system, meaning that if patients have a number of joint swellings, joint ultrasound, tendon ultrasound, you put it into a calculator, and then it comes up with a probability score. So with that, obviously, with regression, we need a large number of patients. And also we hope to sort of really pin down amongst the 10 tendons, which has the maximum predictive value in this context. 

Marwan Bukhari 7:56 Okay. Well, thank you very much. Thank you. That's very interesting. Thanks, Ilfita. 

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