P125 Can musculoskeletal ultrasound assessment change management decisions in rheumatoid arthritis patients with moderate disease activity?
Authors: Crawshaw Helena , Rubio-Cirilo Laura , Johnson Hilary , Jamal Safwan , Hickey Sarah , Gunn Jessica , Ali Iman , Coombes Gill , Acebes Carlos 
Published: April 2024

Abstract

Background/Aims
To evaluate the impact of musculoskeletal ultrasound (MSUS) assessment on treatment escalation decisions in patients with moderately active rheumatoid arthritis (RA) on csDMARDs. To determine the level of concordance between MSUS assessment and Disease Activity Score in 28 joints (DAS28) in patients with moderately active RA.

Methods
During a four-month period, consecutive patients with: an established diagnosis of RA, a DAS-28 of 3.2-5.1, inadequate response to at least 2 csDMARDs and indication to escalate to b/tsDMARDS were enrolled. All patients underwent a MSUS exam (B and PD modes) of the bilateral five-joint count including wrists and 2nd and 3rd MCP and PIP (5USJC). The US exam was extended to symptomatic joints (tender/swollen) of the DAS 28-joint score (28USJC) and a comprehensive 78 joint count (78USJC). For each of the three US exams a total US score and a EULAR/OMERACT US (EOUS) score was calculated. A five-point Likert scale (pre and post MSUS) assessed the patient and referring clinician’s desire to escalate treatment. After the referring clinician reviewed the MSUS assessment, patients were classified into two groups according to the escalation decision. The data was analysed to identify the differences between the two groups and the correlation between the DAS-28 score and the US assessment.

Results
27 patients were included. The mean (SD) age was 56.1 years (12.5), 66.7% were female and the mean time (SD) since diagnosis was 87.8 (24.9) months. 63% were anti-CCP positive and 59% were RF positive. The mean (SD) DAS 28 PCR score was 4.4 (0.7). Following MSUS assessment, there was a change in the initial decision to escalate treatment in 66.7% patients. Using the Likert score, the desire to escalate treatment reduced post US assessment across all groups (statistically significant in the patient group). Treatment escalation was associated with a higher MSUS score (univariate analysis OR &gt; 1) across all assessments (5USJC, 28USJC, 78USJC and EOUS (p &lt; 0,05)). The 78USJC was most reliably aligned with the treatment decision (p = 0.009). A higher swollen joint count (SJC) and higher DAS-28 score correlated with treatment escalation (p &lt; 0.05), whilst longer disease duration was associated with a lower likelihood of treatment escalation (p &lt; 0.05). Comparing MSUS assessment and clinical assessment, results demonstrated poor concordance between all variables of the global DAS-28 score and MSUS score, with the exception of the SJC which showed statistically significant correlation.

Conclusion
The addition of the MSUS assessment to the DAS 28-score in RA patient with moderately active disease has impacted the management decision in in 66.7% of our patients. The addition of MSUS to clinical assessment may allow tailoring of treatment escalation decisions. This study demonstrated poor correlation between clinical assessment with DAS-28 score and MSUS assessment in all domains other than swollen joint score.

Disclosure
H. Crawshaw: None. L. Rubio-Cirilo: None. H. Johnson: None. S. Jamal: None. S. Hickey: None. J. Gunn: None. I. Ali: None. G. Coombes: None. C. Acebes: None.