P116 Systematic review of the prevalence of foot disease activity in patients classed in disease activity score-28 remission
Authors: McIlwaine Kirsty , Hendry Gordon J 
Published: April 2023

Abstract

Background/Aims
The disease activity score-28 (DAS-28) is commonly used in rheumatoid arthritis (RA) to identify people in remission, low, moderate and high disease activity to guide medical management. The DAS-28 omits foot joints and recent research suggests that this may place people with foot disease at risk of poor outcomes. However, little is known concerning the prevalence of foot disease amongst people with RA who are considered to be in remission according to the DAS-28. The aim of this review was to estimate the prevalence of foot disease activity in patients classed in DAS-28 remission.

Methods
Databases included in the search were MEDLINE, CINAHL, AMED and HSNAE. Keywords including “Rheumatoid arthritis”, “disease activity score”, “remission”, “foot joint”, “ankle joint”, “clinical examination”, “ultrasound” and “synovitis” and synonyms using MeSH terms comprised the search strategy. Studies which reported the prevalence of foot disease activity in patients classed in DAS-28 remission were included in this review. Participants were diagnosed with RA, and reported foot disease prevalence from clinical examination (CE), or musculoskeletal ultrasound (MSUS) assessments. Methodological quality of studies were independently assessed by two researchers using the Joanna Briggs Institution prevalence critical appraisal tool (JBI PCAT). Results were subject to narrative synthesis and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement.

Results
Of 44 studies screened for eligibility, 7 were included and a further 2 that met inclusion criteria identified from reference lists were included. A total of 933 participants (mean age range 44-63 years) took part across 9 included studies. Five studies used MSUS (B-mode synovial hypertrophy/power Doppler) while 4 used clinical examination (tenderness/swelling) to identify synovitis. Significant variation across included studies was apparent for foot and ankle sites assessed and method of scoring for the presence of foot disease. For presence of synovitis in one or more foot joints assessed, synovial hypertrophy prevalence detected using B-mode MSUS ranged from 23.4-88.6% (4 studies, n = 687). Synovitis affecting one or more metatarsophalangeal joint (MTPJ) detected using power Doppler was present in 7.5% (1 study, n = 125). Synovitis detected clinically affecting any foot joint was present in 35-43% (3 studies, n = 542). Joint tenderness was detected in 1 or more MTPJs in 6.3% (1 study, n = 187). Methodological quality was generally high, ranging from 7-9/9.

Conclusion
Methodological quality was high but heterogeneous approaches for foot synovitis assessment and scoring were adopted across included studies, making comparisons difficult. The results of this review suggest that foot synovitis is common in people who are classed as in DAS-28 remission. These patients may be at risk of ongoing foot problems and poor functional and radiographic outcomes.
Disclosure
K. McIlwaine: None. G.J. Hendry: Grants/research support; Currently receiving NIHR HTA funding.