Background
Synovitis (inflamed joint synovial lining), in rheumatoid arthritis (RA) can be assessed by clinical
examination (CE) or ultrasound (US).
Objective
To investigate the added value of US, compared to CE alone, in RA synovitis, to clinical and
cost-effectiveness.
Data sources
Electronic databases, inception-October 2015, including MEDLINE, EMBASE and Cochrane
Databases.
Review methods
A systematic review sought RA studies, comparing additional US with CE. Heterogeneity in
intervention, comparators and outcomes precluded meta-analyses. Systematic searches of costeffectiveness
and US, and treatment-tapering studies (not necessarily including US) were
undertaken.
Mathematical model
A model was constructed that estimated, for patients in whom drug tapering was considered, the
reduction in costs of disease modifying drugs (DMARDs) and serious infections, at which the
addition of US had a cost per quality adjusted life year (QALY) gained of £20,000 and £30,000.
Further, the reduction in the costs of DMARDs at which US become cost-neutral was also
estimated.
For patients in whom dose escalation was being considered, the reduction in patients not
escalating treatment and in serious infections at which the addition of US had a cost per QALY
gained of £20,000 and £30,000 was estimated. The reduction in patients escalating treatment for
US to become cost-neutral was also estimated.
Results
Fifty-eight studies were included. Two RCTs compared adding US to a DAS-based treat-to-target
strategy for early RA patients. The addition of PDUS to DAS28 based treat-to-target strategy in
TaSER reported no significant between group difference for change in DAS44. This study found
the PDUS group had significantly more patients attaining DAS44 remission (p=0.03). ARCTIC
found the addition of PDUS and GSUS to a DAS based strategy did not produce a significant
between group difference in the primary endpoint: composite DAS<1.6, no swollen joints, and no
progression in van der Heijde-modified total Sharp Score (vdHSS). ARCTIC did find the erosion
score of vdHS had a significant advantage for US group (p=0.04). Erosion in the TaSER study
did not find a significant group difference. Other studies suggested PDUS was significantly
associated with radiographic progression, and that US had added value for wrist and hand joints
rather than foot and ankle joints. Heterogenity between trials made conclusions uncertain.
No papers were identified reporting cost-effectiveness of US in monitoring synovitis. The model
estimated an average reduction of 2.5% in costs of biological disease-modifying anti-rheumatic
drug (bDMARDs) would be sufficient to offset the costs of three-monthly US. The money could
not be recouped if oral methotrexate was the only drug used.
Limitations
Heterogeneity of trials precluded meta-analysis. Therefore, no summary estimates of effect were
available. Additional costs, and health related quality of life decrement, relating to a flare
following tapering or disease progression have not been included. The feasibility of increased US
monitoring has not been assessed.
Conclusion
Limited evidence suggests US monitoring of synovitis could provide a cost effective approach to
selecting RA patients for treatment tapering or escalation-avoidance. Considerable uncertainty
exists for all conclusions. Future research priorities include evaluating US monitoring of RA
synovitis in longitudinal clinical studies.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)