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Section 15 Rheumatology
II Rheumatoid ArthritisJoint damage in rheumatoid arthritis is marked by the development of pannus, which is the invasive region of synovium that erodes into cartilage and bone. Magnetic resonance imaging and ultrasound can distinguish synovial pannus from cartilage and synovial fluid and thus can detect pannus as it invades joint structures. The use of intravenous contrast materials, such as gadolinium, permits accurate assessment of synovial invasion and volume. MRI has replaced arthrography for the investigation of large joints, such as the knees. Some studies have shown high-resolution MRI to be effective in evaluating erosions in small joints1; however, the use of MRI and ultrasound to monitor response to therapy is still experimental because of a lack of uniform standards for judging damage. Although most erosions persist or progress, up to one quarter of them heal spontaneously. Because of the lack of standardization, plain radiographs remain the gold standard for following disease progression.
1. Chen TS, Crues JV, Ali M, et al: Magnetic resonance imaging is more sensitive than radiographs in detecting change in size of erosions in rheumatoid arthritis. J Rheumatol 33:1957, 2006 [PMID 16881098]
Cardiovascular disease accounts for about 40% to 45% of deaths in rheumatoid arthritis (RA) patients. Some data suggest that vigorous treatment of RA might decrease the risk of cardiovascular events.1
Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, may have cardiovascular toxicity, although this is controversial. A case-controlled study found that treatment with nonselective NSAIDs was associated with a reduction in the risk of acute myocardial infarction (AMI)2; in fact, the reduction in AMI risk was consistent across all disease-modifying antirheumatic drugs, including methotrexate and cyclooxygenase-2 inhibitors, but not in biologic agents. The risk of AMI was increased with the use of glucocorticoids.
1. Pham T, Gossec L, Constantin A, et al: Cardiovascular risk and rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine 73:379, 2006 [PMID 16690341]
2. Suissa S, Bernatsky , Hudson M: Antirheumatic drug use and the risk of acute myocardial infarction. Arthritis Rheum 55:531, 2006 [PMID 16874796]
The human monoclonal antibody adalimumab can be used in combination with methotrexate. In a multicenter, randomized, double-blinded study in which patients were given adalimumab and methotrexate combination therapy, 49% of patients with early and aggressive rheumatoid arthritis exhibited disease remission after 2 years.1
1. Breedveld FC, Weisman MH, Kavanaugh AF, et al: The PREMIER study: a multicenter, randomized, doubled-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis Rheum 54:26, 2006 [PMID 16385520]