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Using ultrasonography to facilitate best practice in diagnosis and management of RA

Nature Reviews Rheumatology volume 5, pages 698–706 (2009)Cite this article

Abstract

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Key Points

  • Published evidence supports the validity, reliability and feasibility of ultrasonography in the setting of inflammatory arthritis

  • Ultrasonography is useful at all stages of the assessment and management of inflammatory arthritis, from early undifferentiated disease to established rheumatoid arthritis

  • It can facilitate early and accurate diagnosis, sensitive quantification of disease activity and extent, timely instigation of tailored management, monitoring of response to therapy, and measurement and prediction of long-term outcomes

  • Patient-friendly qualities and good safety make it a useful tool to obtain immediate information in the clinical setting, and also enables direct visualization of joint aspiration, injection and biopsy procedures

  • Ultrasound assessment can be particularly helpful in diagnostic differentiation and disease classification in uncertain cases

  • Imaging with this modality suggests that notable disease activity continues after remission is clinically determined

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Figure 1: Grayscale and power Doppler ultrasound images of synovial hypertrophy in patients with rheumatoid arthritis.
Figure 2: Grayscale ultrasonography demonstrating erosion of the lateral aspect of the fifth metatarsophalangeal joint in a patient with rheumatoid arthritis, confirmed in a | the longitudinal and b | transverse planes.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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    Andrew K. Brown

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The author declares that he has been a member of a speaker's bureau (honoraria) for Abbott, Pfizer, Schering-Plough and Wyeth, and has received grant/research support from Abbott, Schering-Plough and Wyeth.

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Brown, A. Using ultrasonography to facilitate best practice in diagnosis and management of RA. Nat Rev Rheumatol 5, 698–706 (2009). https://doi.org/10.1038/nrrheum.2009.227

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