New Guidelines for Spondyloarthritis Imaging Issued by EULAR

Janis C. Kelly

April 10, 2015

The first recommendations designed to help clinicians make the best use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA) were published online April 2 by an expert task force assembled by the European League Against Rheumatism (EULAR).

The task force, led by Peter Mandl, MD, from the Division of Rheumatology, Medical University of Vienna, Austria, developed 10 recommendations that addressed all currently available imaging modalities, including conventional radiography (plain film), ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography, single-photon-emission CT, dual-emission X-ray absorptiometry, and scintigraphy.

Dr Mandl told Medscape Medical News, "We hope that the recommendations are easy to understand for clinicians in their daily routine. With regards to difference to previous practice, perhaps the most important change is that we do not recommend scintigraphy nor ultrasound (which was or is still used by some centers) for the diagnosis of sacroiliitis, and furthermore that we do recommend US and MRI for monitoring, particularly for peripheral SpA."

Lianne S. Gensler, MD, director, Ankylosing Spondylitis Clinic, University of California, San Francisco, who was not involved in the study, told Medscape Medical News, "I'm so pleased to see these guidelines being published. This is a good first attempt at putting into writing what we should be doing in diagnosis and monitoring of SpA. For example, we occasionally see a CT scan done to diagnose sacroiliitis. The recommendations state that you should only be using plain films and MRI to diagnose axial SpA. CT scan is not recommended as first-line."

Among the key EULAR recommendations:

  • Axial SpA: for diagnosis: conventional radiography of the sacroiliac joints first, MRI if needed; for monitoring disease activity: MRI of the sacroiliac joints and/or spine; for monitoring structural changes: X-ray of the sacroiliac joints and/or spine; for predicting outcome and severity: conventional radiography; for predicting treatment effect: MRI.

  • Peripheral SpA: US or MRI for diagnosis and for monitoring disease activity and structural changes.

  • Suspected spinal fracture in axial SpA: conventional radiography.

  • Osteoporosis in axial SpA without syndesmophytes in the lumbar spine: conventional radiography; with syndesmophytes in the lumber spine on conventional X-ray: hip dual-emission X-ray absorptiometry, supplemented by either spine dual-emission X-ray absorptiometry in lateral projection or quantitative CT of the spine.

Dr Mandl summarized the guidance on when to use MRI as: Use it in all cases when X-rays are negative but clinical doubt remains. He said, "An additional consideration for starting with MRI right away is in case of young patients or those who are pregnant."

Dr Gensler agreed with using MRI first in children to limit radiation exposure but expressed concern about starting with MRI in adults. "I still start with a plain film in adults. I don't care how long or short their reported symptoms are. We have found in reviewing medical records that patients' recall of symptom onset is very poor."

Dr Gensler also questioned the recommendation for using MRI for routine monitoring of SpA disease activity. "How are you going to use that information? Currently the primary reason to start a [tumor necrosis factor] inhibitor is based on symptoms. We have little evidence that doing an MRI, especially after you have started treatment, is going to change management. We do not have enough evidence right now to support routine monitoring with MRI in axial SpA." Dr Gensler said. She also raised the concern that overuse of MRI might trigger more restrictive preapproval processes such that it will become harder to get MRIs approved even when they are really needed

How the EULAR SpA Task Force Devised Guidance

The 22 EULAR task force members included rheumatologists, radiologists, and methodologists from 11 countries. They developed 12 research questions to guide the data review and development of recommendations. These covered the role of imaging in diagnosing axial or peripheral SpA, monitoring inflammation and damage, predicting outcome and treatment response, and detecting spinal fractures and osteoporosis.

Five task force members performed a literature review that included 158 articles published in English up to January 2013. The entire task force then participated in developing and scoring the strength of the recommendations.

The task force rated the strength of all 10 recommendations at 8.9 or higher (scale of 1 - 10), even though five of the 10 recommendations were based only on nonexperimental descriptive studies (comparative, correlation, or case-control) and/or on expert opinion.

EULAR Allowed More Potential Conflicts of Interest Than ACR

This process differed in several ways from that used in the axial SpA guideline collaborative project of the American College of Rheumatology (ACR), the Spondylitis Association of America, and the Spondyloarthritis Research and Treatment Network. The axial SpA guideline was presented in draft form at the 2014 ACR annual meeting and is now being prepared for publication.

The first difference was in possible conflicts of interest. Dr Gensler said the ACR required every committee and subcommittee to include 51% of members without any conflicts of interest, including 51% of the oversight committee, 51% of the literature review team (on which Dr Gensler served), and 51% of the voting panel. Only five of the 22 EULAR authors reported no conflicting interests.

Another difference was in how the strength of the recommendations was determined. According to Dr Gensler, in developing the ACR guidelines, the roles of developing the questions to be addressed, preparing the literature review and proposed recommendations, and voting on the strength of recommendations were separate.

"Nobody who served on a literature review panel also served on the voting panel, and the executive committee came up with the key questions but did not perform the literature review, make recommendations, or vote," Dr Gensler said.

The whole expert panel (including those who had done the literature review), ranked the EULAR recommendations, using a 0 to 10 visual analogue scale, with scores reflecting both research evidence and expert opinion.

EULAR Highlighted Unanswered Question in SpA Imaging

Dr Mandl and Dr Gensler agreed about the need for more solid clinical trial data on SpA, including imaging studies.

Dr Mandl said, "It was surprising how few studies were performed which actually evaluated the metric properties of X-ray as a diagnostic tool in SpA, despite the fact that it has been and continues to be the cornerstone imaging tool in this regard. I suppose the question of how and to what extent we can include MRI and US as imaging tools for the monitoring of peripheral and axial SpA will be crucial questions in the years to come."

Dr Gensler added, "There is a very great unmet need to study peripheral [SpA] in clinical trials not including people with psoriatic arthritis."

Plain Film X-rays, Physical Exam Still Most Important in SpA

Imaging is unlikely to replace diligent application of well-honed clinical skills in diagnosis and management of SpA, however.

"First and foremost, we need to be good rheumatologists and do thorough physical exams. If the patient has persistent peripheral arthritis and synovitis, you do not need an US or MRI for diagnosis," Dr Gensler said.

Researchers first presented the clinical guidelines at the European League Against Rheumatism (EULAR) Congress 2014.

Twenty of the 22 coauthors disclosed potential conflicting interests that included speaking fees, consulting fees, and/or research grants from AbbVie, BMS, GE Janssen, MSD, Pfizer, Roche, Novartis, Amgen, AstraZeneca, Augurex, Boehringer Ingelheim, Celgene, Centocor, Chugai, Covagen, Daiichi, Eli Lilly, GSK, Janssen Biologics, Novo-Nordisk, Otsuka, Sanofi-Aventis, Vertex, Mundipharma, Hospira, Orion, Takeda, and UCB. The other authors and Dr Gensler have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online April 2, 2015. Full text

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