MRI Treat-to-Target Strategy Fails to Help RA Patients Reach Remission

Targeting the absence of osteitis along with clinical remission in a 2-year MRI treat-to-target strategy in rheumatoid arthritis (RA) patients does not affect the long-term probability of achieving DAS28-CRP remission, a new study found.¹

Investigators conducted the IMAGINE-more, an observational study, to compare a 2-year MRI treat-to-target strategy targeting the absence of osteitis and clinical remission with a conventional treat-to-target strategy targeting clinical remission alone. IMAGINE-more branched off the study IMAGINE-RA which evaluated the strategy targeting only clinical remission.² The team ultimately aimed to see if targeting the absence of osteitis alongside clinical remission in MRI treat-to-target strategy improved clinical and radiographic outcomes over 5 years in patients with RA in clinical remission.¹

“In accordance with the primary results from the IMAGINE-RA trial, these long-term data do not support systematic use of MRI to guide treatment in patients with RA in remission,” wrote investigators, led by Signe Moller-Bisgaard, MD, PhD, from the department of rheumatology at Slagelse Hospital in Denmark.

The key primary outcomes were remission, defined as a Disease Activity Score in 28 Joints C reactive protein (DAS28-CRP) of < 2.6, and no radiographic progression, indicated by a van der Heide-modified Sharp score of ≤ 0 which demonstrates the joint damage did not worsen or improve compared to baseline. The key secondary outcomes were disease activity (DAS28-CRP), change in total van der Heide-modified Sharp score, change in MRI osteitis (OMERACT RAMIS) score, and change in functional level (Health Assessment Questionnaire) from baseline to the 5-year follow-up. Investigators also assessed for ACR/EULAR 2011 criteria, SDAI remission (SDAI ≤3.3), CDAI remission (CDAI ≤ 2.8), patient Visual Analogue Scale (VAS) global, patient VAS pain, and patient VAS fatigue.

After recruiting participants from May 2014 to April 2017, the IMAGINE-more sample included 131 patients, with 67% women, a mean age of 61.2 years, a disease duration of 9.5 years, a baseline DAS28-CRP of 1.9 (IQR, 1.6 to 2.2), and a van der Heide-modified Sharp score of 16.0 (IQR, 7.0 to 36.0). In total, 80% of the patients in the new MRI treat-to-target group and 75% of patients in the conventional treat-to-target group were in remission (odds ratio [OR], 2.00; 95% confidence interval [CI], 0.76 to 5.28; P = 0.16). Furthermore, 24% of the patients in the new treatment group and 26% in the conventional treatment had no radiographic progression (OR, 0.70; 95% CI, 0.28 to 1.71; P = 0.43).

The team observed no differences between the 2 treatment groups for the 4 key secondary outcomes. For the other secondary outcomes, they did observe patient VAS pain was the only outcome to significantly improve in the original MRI treat-to-target group compared with the conventional treat-to-target group (difference between groups: least squares mean, - 7.0; 95% CI, - 12.8 to -1.2; P = .018). Patients in the MRI treat-to-target group often had a lower VAS global (−5.9; 95% CI −11.9 to 0.0; P =.051)

“The primary results from this long-term study are consistent with the 2-year findings from the IMAGINE-RA randomized clinical trial,” investigators wrote. “DAS28-CRP remission rates remained high after 5 years. However, a small decrease in remission rates from 2 to 5 years was observed, with no statistically significant differences between the groups.”

Investigators theorized the reduced remission rates could be because patients had less rigorous follow-ups, and physicians did not have to use treatment algorithms. They also explained how the remission rates could stay high due to both groups being treated with intra-articular glucocorticoids in all swollen joints.

“This was done not only during the first 2 years but also in the follow-up period since this is part of Danish clinical practice,” investigators wrote.

The team outlined several limitations, including the observational design, the small sample size, and patients in IMAGINE-more had more visits carried by a site investigator rather than in an outpatient clinic with a local physician which could have led to bias.

“…among patients in remission, a 2-year combined MRI treat-to-target and clinical treat-to-target strategy as compared with a conventional clinical treat-to-target strategy alone, had no effect on remission rates and radiographic progression over 5 years,” investigators concluded.

^References

1. ^{Møller-Bisgaard S, Hørslev-Petersen K, Ørnbjerg LM, et al. Long-term efficacy of a 2-year MRI treat-to-target strategy on disease activity and radiographic progression in patients with rheumatoid arthritis in clinical remission: 5-year follow-up of the IMAGINE-RA randomised trial. RMD Open. 2024;10(1):e003945. Published 2024 Mar 15. doi:10.1136/rmdopen-2023-003945}
2. ^{Møller-Bisgaard S, Hørslev-Petersen K, Ejbjerg B, et al. Effect of Magnetic Resonance Imaging vs Conventional Treat-to-Target Strategies on Disease Activity Remission and Radiographic Progression in Rheumatoid Arthritis: The IMAGINE-RA Randomized Clinical Trial. JAMA. 2019;321(5):461-472. doi:10.1001/jama.2018.21362}