The Effect of Biannual Monitoring With Magnetic Resonance Imaging (MRI), X-ray, or Usual Care on Treatment for Inflammatory Arthritis

Study Overview
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Brief Summary
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Inflammatory arthritis is a major cause of permanent joint damage. Joint damage causes functional disability and physical deformity. Many inflammatory arthritis patients develop permanent joint damage within the first two years of disease. Early, aggressive treatment with drugs called disease-modifying antirheumatic drugs (DMARDs) is known to reduce how quickly this damage occurs. Sometimes, however, even when patients' symptoms are under control, the disease continues to cause joint damage. This study will determine if magnetic resonance imaging (also known as 'MRI') conducted every six months provides arthritis specialists with information to help them better treat peripheral inflammatory arthritis patients over the first two years of care. The effect of MRI will be compared to 1) the use of x-ray every six months; and, 2) the frequency at which these tests are usually used. The study will also determine if differences in treatment between the three groups result in differences in the well-being of patients. A total of 186 patients with early signs of inflammatory arthritis will be studied. All participants will have an MRI and x-ray conducted every six months. One-third of participants (62 in total) will only have MRI information sent to their arthritis specialist (MRI group); 62 will have x-ray information sent (X-ray group); and, the remaining 62 will have x-ray information sent only when ordered by the arthritis specialist (Usual Care group). Negative disease progression reports will be sent to the arthritis specialist unless intervention allocation-specific disease progression is detected. In which case, a report blinded to imaging modality will be sent indicating the detection of disease progression relative to the last timepoint of progression, or baseline, as applicable. At any point in the study, the arthritis specialist can request a clinical MRI or x-ray for any participant. Neither the participants nor their doctors will know to which group they are assigned. A computer program will randomly assign participants to one of the three groups using a technique called minimization. This technique accounts for differences between participants that are known to effect disease progression and treatment decisions. Using this technique, participants with similar disease will be evenly distributed between the three groups. The results of this study will have a direct impact on care for new inflammatory arthritis patients. It will determine the benefits, if any, of regular monitoring of disease progression with MRI or x-ray. Using tests proven to help treatment decision-making, arthritis specialists will improve the care provided to new inflammatory arthritis patients.

Detailed Description
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The proposed project is a double-blinded randomized-controlled trial to determine if biannual monitoring of inflammatory arthritis disease progression with 1.0T peripheral magnetic resonance imaging (pMRI) of the 2nd to 5th metacarpophalangeal joints of the worst-effected or dominant hand at baseline compared to conventional radiography of both hands and wrists, or standard of care, alters the frequency of pharmacological treatment escalation at two years. A sample size of 186 (62 per group) is required to determine mean differences in the rate of pharmacological treatment escalation between the three groups with 90% power at a 5% level of significance, assuming a 5% spontaneous remission rate, 15% missing data, and 5% annual attrition.

Official Title
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A Double Blind Randomized Controlled Trial to Compare Biannual Peripheral Magnetic Resonance Imaging, Radiography, and Standard of Care on Pharmacotherapeutic Escalation in Inflammatory Arthritis

Conditions
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Inflammatory Arthritis

Intervention / Treatment
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* Other: MRI
* Other: Radiography
* Other: Standard of Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: At least 18 years of age at study enrollment. At least three swollen joints; OR, Metacarpophalangeal joint(s) positive squeeze test; OR, Metatarsophalangeal joint(s) positive squeeze test; OR, At least 30 minutes of self-reported morning stiffness. At least six weeks of self-reported symptom duration. Exclusion Criteria: Self-reported symptom onset prior to 17 years of age. Medical history of juvenile arthritis Evidence of viral arthritis A concomitant condition with medical priority over inflammatory arthritis, or that contraindicates treatment with DMARDs excluding sulfa allergy or medically controlled, non-terminal liver disease. Refusal to receive DMARD treatment Patients with a psychological deficit, or diminished capacity to provide independent, informed consent Any contraindication to MRI or x-ray Current or planned pregnancy Lactation

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: MRI<br>Biannual disease progression monitoring with peripheral magnetic resonance imaging of the 2nd to 5th metacarpophalangeal joints of the worst-effected or dominant hand at baseline. | Other: MRI<br>* Biannual disease progression monitoring with peripheral magnetic resonance imaging of the 2nd to 5th metacarpophalangeal joints of the worst-effected or dominant hand at baseline. Scored using the Xie-modified rheumatoid arthritis magnetic resonance imaging score (RAMRIS). MRI intervention group also undergoes radiography imaging. Only protocol determined smallest detectable changes on MRI reported.<br>* Other names: Diagnostic imaging: 1T pMRI (OrthOne, ONI Medical Systems);|
| Active Comparator: Radiography<br>Biannual disease progression monitoring with radiography of both hands and wrists. | Other: Radiography<br>* Biannual disease progression monitoring with radiography of both hands and wrists. Scored using the van der Heijde-modified Sharp score. Radiography intervention group also undergoes MRI imaging. Only protocol determined smallest detectable changes on radiography reported.<br>* Other names: Diagnostic Imaging: Conventional radiography.;|
| Placebo Comparator: Standard of Care<br>Diagnostic imaging results (MRI or radiography) reported to upon requisition. | Other: Standard of Care<br>* Diagnostic imaging results (MRI or radiography) reported upon requisition. Standard of Care intervention group undergoes both MRI and radiography imaging. Upon requisition of either MRI or radiography, radiology reports are delivered as per institutional standard of care<br>* Other names: Placebo control: see MRI and radiography interventions.;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The frequency of antirheumatic treatment escalations. |  | Two years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in van der Heijde-modified Sharp score of the hands and feet. |  | Two years | 
| Change in 28-joint disease activity score (DAS28) |  | Two years | 
| Change in health assessment questionnaire (HAQ) score |  | Two years | 
| Change in Xie-modified rheumatoid arthritis magnetic resonance imaging score (RAMRIS) |  | Two years | 
| Change in health utility index - mark 3 (HUI-III) |  | Two years | 
| Change in EQ-5D |  | Two years | 
| Number of smallest detectable changes |  | Two years | 
| Change in the proportion of participants with radiography-determined erosions of the hands, wrists, or feet |  | Two years | 
| Change in the number of radiography-determined erosions of the hands, wrists or feet |  | Two years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Magnetic resonance imaging, Radiography, Randomized controlled trial, Antirheumatic agents