• Signe Møller-Bisgaard, Kim Hørslev-Petersen, Bo Ejbjerg, Merete Lund Hetland, Lykke Midtbøll Ørnbjerg, Daniel Glinatsi, Jakob Møller, Mikael Boesen, Robin Christensen, Kristian Stengaard-Pedersen, Ole Rintek Madsen, Bente Jensen, Jan Alexander Villadsen, Ellen-Margrethe Hauge, Philip Bennett, Oliver Hendricks, Karsten Asmussen, Marcin Kowalski, Hanne Lindegaard, Sabrina Mai Nielsen, Henning Bliddal, Niels Steen Krogh, Torkell Ellingsen, Agnete H Nielsen, Lone Balding, Anne Grethe Jurik, Henrik S Thomsen, and Mikkel Østergaard.
• Department of Rheumatology, Slagelse Hospital, Slagelse, Denmark.
• JAMA. 2019 Feb 5; 321 (5): 461-472.

ImportanceWhether using magnetic resonance imaging (MRI) to guide treatment in patients with rheumatoid arthritis (RA) improves disease activity and slows joint damage progression is unknown.ObjectiveTo determine whether an MRI-guided treat-to-target strategy vs a conventional clinical treat-to-target strategy improves outcomes in patients with RA in clinical remission.Design, Setting, And ParticipantsTwo-year, randomized, multicenter trial conducted at 9 hospitals in Denmark. Two hundred patients with RA in clinical remission (disease activity score in 28 joints-C-reactive protein [DAS28-CRP] <3.2 and no swollen joints) were enrolled between April 2012 and June 2015. The final follow-up visit was April 2017.InterventionsPatients were randomly allocated (1:1) to an MRI-guided vs a conventional treat-to-target strategy. In the MRI-guided group, the treatment goal was absence of MRI bone marrow edema combined with clinical remission, defined as DAS28-CRP of 3.2 or less and no swollen joints. In the conventional group, the treatment goal was clinical remission.Main Outcomes And MeasuresCo-primary outcomes were proportions of patients achieving DAS28-CRP remission (DAS28-CRP <2.6) and with no radiographic progression (no increase in total van der Heijde-modified Sharp score) at 24 months. Significance testing for the primary outcome was based on 1-sided testing. Secondary outcomes were clinical and MRI measures of disease activity, physical function, and quality of life.ResultsOf 200 patients randomized (133 women [67%]; mean [SD] age, 61.6 [10.5] years; median baseline DAS28-CRP, 1.9 [interquartile range, 1.7-2.2]; van der Heijde-modified Sharp score, 18.0 [interquartile range, 7.0-42.5]), 76 patients (76%) in the MRI-guided group and 95 (95%) in the conventional group completed the study. Of these, 64 (85%) vs 83 (88%), respectively, reached the primary clinical end point (risk difference, -4.8% [1-sided 95% CI, -13.6% to + ∞; 1-sided P = .19]) and 49 (66%) vs 58 (62%), respectively, reached the primary radiographic end point (risk difference, 4.7% [1-sided 95% CI, -7.0% to + ∞; 1-sided P = .25). Of 10 key secondary end points, 8 were null and 2 showed statistically significant benefit for the MRI treat-to-target group. Seventeen patients (17%) in the MRI-guided treat-to-target group and 6 patients (6%) in the conventional treat-to-target group experienced serious adverse events.Conclusions And RelevanceAmong patients with RA in clinical remission, an MRI-guided treat-to-target strategy compared with a conventional treat-to-target strategy did not result in improved disease activity remission rates or reduce radiographic progression. These findings do not support the use of an MRI-guided strategy for treating patients with RA.Trial RegistrationClinicalTrials.gov Identifier: NCT01656278.

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