AB0563 DIAGNOSTIC ISSUES IN DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: THE UTILITY OF ULTRASOUND IN STANDARD PRACTICE FOR DIFFICULT TO TREAT RHEUMATOID ARTHRITIS
Authors: W. Elwakil, Y. El Miedany, M. H. Abu-Zaid, M. Elgaafary
Journal: Annals of the Rheumatic Diseases (2024)

<h3>Background:</h3> Management of difficult to treat (D2T) inflammatory arthritis requires meticulous evaluation for the presence or absence of inflammation to support pharmacological and non-pharmacological management strategies. The EULAR Task Force has defined D2T rheumatoid arthritis as patients having persistency of symptoms and/or signs despite failure of at least two biological or targeted synthetic disease modifying anti-rheumatic drugs with different mechanisms of action. Recently, a study suggested amending the suggested EULAR definition to make it more precise and time framed [1]. <h3>Objectives:</h3> 1.To evaluate the role of US in optimal confirmation of a diagnosis of difficult to Treat inflammatory arthritis, the recognition of mimicking diseases and the assessment of inflammatory disease activity. 2.To assess the rheumatologists' certainty for presence/absence of D2T inflammatory arthritis. <h3>Methods:</h3> Patients: RA patients diagnosed to have D2T RA according to the EULAR criteria [1] Study design: Cross sectional retrospective analysis of consecutive D2T RA patients. Patients: Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. The characteristics of the patients and their current/ past sDMARD/bDMARD therapy will be recorded. A diagnostic assessment was carried out by ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints. Scoring: Both Grayscale (GS) and Power Doppler (PD) findings was scored on a 0-3 grade by a semi-quantitative method, and the total US score defined as the sum of GSUS and the PD scores was calculated. Control group: The patients' characteristics, GSUS and PDUS score of US was compared to that reported in cohort of non-D2T RA patients diagnosed according to the ACR/EULAR RA classification criteria and treated according to national guidelines [2]. Intra- and Inter-observer reliability of the US scanning will be carried out. Analysis: The clinical disease activity measures, demographic and laboratory characteristics of the D2T inflammatory arthritis were compared to non-D2T inflammatory arthritis. Also, the certainty of the treating rheumatologist for presence/absence of D2T inflammatory arthritis was assessed by asking the treating rheumatologist to rate their certainty of the diagnosis out of 10, before and after the US assessment. <h3>Results:</h3> This work included 62 D2T patients and 276 RA patients. There was no significant difference between both groups in terms of the mean age which was 58.4 in the D2T group versus 61.2 years and mean disease duration of the disease 15.7±2.6 in D2T vs. 14.8 ± 3.4 months in the control group. DAS-28 [ESR] score was 7.5 in the D2T vs. 2.7 in the control group (p&lt; 0.001), Gray scale US score (19.4 vs 3.2, p=0.001) and Power Doppler US score (15.2 vs 2.7, p=0.001) reflecting significantly higher measures in the D2T-RA group. Tenosynovitis was present in 61.3% (38/62) of the D2T patients versus 16/276 (5.8%) in the control group (p&lt; 0.01). Crystal deposition was present in 19/62 (30.6%) versus 16/276 (5.8%) in the control group (p&lt; 0.001), whereas erosions were present in 29/62 (46.8%) in the D2T cohort versus 14/276 (5.1%) in the control group (p&lt; 0.001). <h3>Conclusion:</h3> US is important in identifying and differentiating patients with D2T inflammatory arthritis. US can visualize pathophysiological changes such as synovitis, tenosynovitis, bone erosions, and crystal deposits at a subclinical level, which makes it an effective technique to identify D2T arthritis and can help guide treatment in this cohort of patients. <h3>REFERENCES:</h3> [1] El Miedany Y et al. The identification, goals and principles of difficult-to-treat inflammatory arthritis: a consensus statement. Egypt Rheumatol Rehabil 2023; 50:56. [2] El Miedany, Y. et al. Egyptian guidelines for the treatment of Rheumatoid Arthritis — 2022 update. Egypt Rheumatol Rehabil 2022; 49: 56. <h3>Acknowledgements:</h3> <b>NIL.</b> <h3>Disclosure of Interests:</h3> <b>None declared.</b>