SP0141 DOES IMAGING LEAD TO OVERDIAGNOSIS AND OVERTREATMENT?
Authors: Duncan Porter
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> The use of musculoskeletal ultrasound (MSUS) and magnetic resonance (MR) imaging is widespread in the diagnosis and management of patients with rheumatic disease. Interpreting the images, and their implication for clinical management is challenging, particularly in the community, in mild/early disease, when there is discordance between clinical and imaging findings, and in the presence of co-morbid joint disease. <h3>Objectives:</h3> – to review the evidence about whether the use of imaging results in over-diagnosis and over-treatment Specifically, the following issues will be addressed, using rheumatoid arthritis as the exemplar: To review the prevalence of 'abnormal" MSUS and MR findings in the general population To understand the prevalence and significance of sub–clinical joint inflammation To summarise the evidence from clinical trials about the risks/benefits of treating to a target of imaging (rather than clinical) remission <h3>Methods:</h3> If clinicians are to interpret the available imaging correctly, several issues are pertinent. Firstly, it is important to understand the prevalence of erosions, synovitis and bone marrow oedema in the general population, in different joints, at different ages and in the presence of co-morbid conditions such as osteoarthritis. Secondly, in RA what are the implications of sub-clinical inflammatory changes for disease progression? Thirdly, do clinical trials support the hypothesis that 'treat to target" strategies should aim at a target of 'imaging remission" rather than clinical remission? The results of the TaSER, ARCTIC and RA-IMAGINE trials will be reviewed to identify if the systematic, routine use of imaging results in over-treatment or clinical harm. Lastly, the possibility that imaging could have a role in reducing over-treatment will be discussed. <h3>Conclusion:</h3> It is impossible to interpret the results of imaging correctly, without knowing the clinical context. Clinicians need to understand the value and the limitations of imaging, and should not pursue a simplistic or binary approach when interpreting the results - otherwise over-diagnosis and over-treatment will be the result. To date, the evidence from RCTs in the management of RA suggest that a 'treat-to-target" approach should aim for clinical and not imaging remission. <h3>References:</h3> [1] Dale J, Stirling A, Zhang R, Purves D, Foley J, Sambrook M, et al. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis. 2016 Jun;75(6):1043–50 [2] Haavardsholm EA, Aga A-B, Olsen IC, Lillegraven S, Hammer HB, Uhlig T, et al. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ. 2016 Aug 16;:i4205. [3] Møller-Bisgaard S, Hørslev-Petersen K, Ejbjerg B, Hetland ML, Ørnbjerg LM, Glinatsi D, et al. Effect of Magnetic Resonance Imaging vs Conventional Treat-to-Target Strategies on Disease Activity Remission and Radiographic Progression in Rheumatoid Arthritis: The IMAGINE-RA Randomized Clinical TrialEffect of MRI vs Conventional Treat-to-Target Strategies on Disease Activity Remission in RAEffect of MRI vs Conventional Treat-to-Target Strategies on Disease Activity Remission in RA. JAMA. 2019 Feb 5;321(5):461–72 [4] Mangnus L, van Steenbergen HW, Reijnierse M, van der Helm-van Mil AHM. Magnetic Resonance Imaging–Detected Features of Inflammation and Erosions in Symptom-Free Persons From the General Population. Arthritis &amp; Rheumatology. 2016;68(11):2593–602 <h3>Disclosure of Interests:</h3> None declared