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Ultrasound in RA
How I Use Musculoskeletal Ultrasound in the Management of My Rheumatoid Arthritis Patients

Released: April 21, 2016

Expiration: April 20, 2017

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As rheumatologists, we have several established tools for monitoring disease activity in patients with rheumatoid arthritis, such as the RAPID3, CDAI, SDAI, and DAS28. You have likely heard that musculoskeletal ultrasound can be a useful addition to the toolbox, but perhaps you are unsure exactly how it can help in your practice. Musculoskeletal ultrasound is a great tool for monitoring our patients’ disease and specifically for visualizing disease damage and subclinical inflammation. In my practice, musculoskeletal ultrasound helps me make key treatment decisions, and I often use it when I am unsure whether to intensify therapy. In the case discussions that follow, I will explain 2 opposite scenarios in which ultrasound was a useful tool for deciding how to proceed with treatment.

Case Example 1: Patient With Stable Disease Experiencing Discomfort
I recently saw a long-time patient who had been receiving standard therapy. She has advanced disease including ulnar deviation, synovial hypertrophy with pannus formation and interosseous wasting. Her acute-phase reactants, ESR and CRP, have been stable for the past year or so, but she was complaining of some discomfort in her hands. On clinical exam, she did not have any tender joints or appreciable synovitis. Unsure about how to proceed, I used musculoskeletal ultrasound to determine if there was any detectable synovitis or subclinical inflammation that would warrant intensifying her treatment. The exam revealed no ultrasonographic evidence of subclinical inflammation and no new erosions. Therefore, I decided to continue her current therapy and add a short course of analgesics and NSAIDs for her discomfort. In the absence of subclinical inflammation, I could not justify escalating her rheumatoid arthritis treatment and increasing her risk for adverse events.

Case Example 2: The Reluctant Patient
In another recent case, I saw a patient who felt relatively well and was reluctant to escalate her therapy despite experiencing mild pain and swelling in multiple joints. Her clinical exam showed some swelling and tenderness to palpation over some of her MCP joints but was otherwise normal. This time, I performed musculoskeletal ultrasound and found synovial effusions and a robust Doppler signal in several of her MCP joints. These visual data helped us see why she was experiencing pain in her hands, and I was then able to easily persuade her to escalate her therapy despite her previous hesitation. I am confident that she will benefit from her new regimen.

Figure. Ultrasound Image of Synovitis in a Wrist.

Summary of My Approach
To summarize my approach, a patient’s history and clinical exam are the most important tools for determining treatment approaches. However, if musculoskeletal ultrasound reveals active disease in a patient who has been on standard treatment, I would definitely recommend escalating therapy. Ongoing subclinical inflammation has been shown to increase the risk of radiographic progression in patients with rheumatoid arthritis. I routinely perform ultrasounds, even in patients who are in clinical remission based on all disease activity scores and report feeling well, for this very reason. Alternatively, if there is no evidence of ongoing synovitis in a patient who nonetheless complains of discomfort, it is reasonable to defer intensification of therapy.

As with any diagnostic modality, there are limitations to musculoskeletal ultrasound. The main one being that it is largely operator dependent, and most rheumatologists are not familiar or trained in the techniques and use of the equipment. It can also be time consuming to incorporate into everyday clinical practice, particularly when examining more than 1 joint. That being said, it is significantly more sensitive than clinical exam at detecting subclinical inflammation, synovitis, and erosions, and it is a procedure that can be easily performed in clinic during a routine visit.

More on Management of Rheumatoid Arthritis
To learn more about the tools to determine management strategies in rheumatoid arthritis, selecting and using rheumatoid arthritis treatment, and other management considerations, please check back in the coming months for interactive, CME-certified video discussions among key rheumatology experts. For now, we would like to hear from you. Have you incorporated musculoskeletal ultrasound into your management approach for patients with rheumatoid arthritis? I encourage readers to post their thoughts and questions in the comments section below.

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