MRI-guided treatment does not improve clinical remission for rheumatoid arthritis patients

An MRI-guided strategy for treating patients with rheumatoid arthritis (RA) showed no benefits over conventional treat-to-target approaches, according to a Feb. 5 study published in JAMA. The authors recommend adhering to current RA treatment guidelines.

Results of the IMAGINE-RA clinical trial also found MRI showed no benefit in radiographic progression compared to traditional approaches.

The treatment target for RA is clinical remission, defined as no clinical signs or symptoms of disease activity. Early treatment strategies, known as “treat-to-target” approaches, have made clinical remission achievable. However, up to 30 percent of these patients develop structural damage, causing researchers to consider if a more sensitive joint inflammation modality like MRI could improve clinical and radiographic outcomes.

In the trial, the team enrolled 200 patients with RA in clinical remission (defined as a disease activity score in 28 joints-C reactive protein (DAS28-CRP of less than 3.2 and no swollen joints) from nine centers in Denmark between April 2015 and June 2015. Participants were randomly divided (1:1 ratio) into an MRI-guided group with a treatment goal of bone marrow edema with clinical remission (DAS28-CRP less than 2.6) and no swollen joints, and a treat-to-target group with a goal of clinical remission.

Of the 200 patients enrolled, 76 in the MRI group and 95 in the conventional group competed the study. Sixty-four patients in the MRI group reached the primary clinical endpoint compared to 83 in the conventional treatment cohort. Additionally, 49 participants and 58 patients, respectively, reached the radiographic endpoint.

At 24 month follow-up, the team also measured 10 secondary outcomes (clinical and MRI measures of disease activity, physical function and quality of life) and found that most remained the same.

“These findings do not support the use of an MRI-guided strategy for treating patients with RA,” wrote first author Signe Møller-Bisgaard, MD, PhD, with Slagelse Hospital in Slagelse, Denmark, and colleagues.

“One potential explanation for the lack of improved remission rates in the MRI-guided treat-to-target group is that participants randomized to this group had a lower rate of remission at baseline than participants in the conventional treat-to-target group (86% vs 96%),” Møller-Bisgaard, and colleagues wrote.

In a related editorial, Daniel Aletaha, MD, and Josef S. Smolen, MD, both with the Medical University of Vienna in Austria, agreed that the Møller-Bisgaard trial demonstrated MRIs ineffectiveness for guiding RA treatment, but suggested it remains an important part of evaluating joints in these patients.

“Sonography and MRI are excellent diagnostic tools that should be used to evaluate symptoms and confirm diagnoses in joints that are difficult to examine clinically, such as the shoulder or foot joints or in tendon sheaths,” the authors concluded. “However, these uses of imaging are diagnostic, rather than guiding treatment.”