Using the EULAR imaging recommendations

10 August 2016

In 2013 EULAR made 10 recommendations on the role of imaging in the management of rheumatoid arthritis, including diagnosis, monitoring and predicting outcome and response to treatment. Dr Alvin Wells (USA) and Dr Orrin Troum (USA) discuss how they apply these recommendations in clinical practice.

Hi, I'm Alvin Wells the Director of the Rheumatology Immunotherapy Center in Franklin Wisconsin, and I'm Orrin Troum Clinical Professor of Medicine at the Keck School of Medicine at the University of Southern California and in private practice in Santa Monica California. We are excited to bring to you a new education opportunity for rheumatologists; a new site called

Today Orrin and I are going to discuss some new imaging guidelines. These have been proposed by EULAR, and at best it has been a number of years now. It came up with ten different recommendations and the recommendations include how to make the diagnosis, when to do monitoring and also for prognosis; the prognosis for who is at increased risk for damage, also prognosis in response to therapy. They also talked about monitoring the disease and which joints you want to image, and then how we use imaging for future endeavors.

So Orrin first I want to talk about what do you use the in product, do you use conventional radiography, or do you use MR ultrasound? How do you use those on a daily basis?  I think in my practice, and what was proposed by the EULAR guidelines, is that we are not leaving conventional radiography behind. We still at least have to advocate the use of x-rays of the hands and the feet to be done initially, but also many of us are using ultrasound and MRI as a prognostic indicator. I agree and I think just like Orrin says, right now for all the clinical trials for FDA approval and for approval for other agencies, conventional radiology is what we use.

Whether EULAR guidelines talk about other imaging diagnosis, it definitely tells us that the MRI and ultrasound can detect more synovitis, so which joints do you look at when we think about MRI when you wanted to rule out synovitis? Typically for not just synovitis but also osteitis or bone marrow edema which is the distinct property that MRI has to predict, it is the best predictor of future erosions, typically the small joints; the hands, wrists and feet can be imaged. Now I like that and this is really true, so unlike the MRI, the ultrasound does not show bone marrow edema. I get asked all the time "which joints do you look at for the clinical trials?", We look at 28 different joints, studies we are looking at can look at 10 joints. But the goal, and EULAR talks about this in their guidelines, is to get the examination down to 15 to 20 minutes. You can highlight whether you're looking at 5 or 7 joints. It turns out that the ultrasound of the wrist and the second and third metacarpophalangeal joints are the ones you want to highlight the most.

Orrin when you look at the MRI, what about the MTP joints, any dishes there, which joints do you want to look at when you think about the foot? Typically when you get an MRI of the foot you're going to get the whole foot but the fourth and fifth are the ones that are typically seen first. I would just also mention the fact that in the EULAR guidelines, other issues were brought up somewhat different from ACR recommendations, including the prognosis and that advanced imaging can be used for prognostication and also to assess remission, and then for monitoring. There is somewhat a difference between the EULAR an ACR guidelines, but EULAR made those specific recommendations with the data that they had access to and I think they are warranted. Orrin you bring up a very good point because I get asked all the time, not only by other physicians but by patients: "what do you do to monitor disease and how do you begin to say who can wrap up their therapy and who can taper off the therapy?". So do you use MRI to help you make the decision to add a biologic, to taper a biological, or to change drugs, how do you use that in your practice? I may use MRI and also ultrasound initially to see or to prognosticate which patients are at the highest risk, those that have the most synovitis, tenosynovitis or with MRI with osteitis or bone marrow edema, I might be more prone to using advanced therapy quicker. I think that's really true and I think it echoes what I do in my practice as well, I still pride myself in my clinical exam I do a Cy dye, I do a DAS on patients but there are some patients that can still be difficult but they have more hand disease/foot disease; we definitely know that ultrasound and MR can actually give us some guides for that.

What do you see the future of MRI for: its clinical trials or for using in a routine practice? An important point and with the validation, and there is a validated scoring system, that RA MRI scoring system that is useful I think ultimately MRI is going to be more useful for clinical trials as there are going to be fewer patients that are needed in a shorter period of time for those clinical trials.

I think that pretty much summarizes what the EULAR recommendations have made as of the past few years and where we're going to go forward towards in the future. I think that's a good summary. I think again to reiterate, Orrin and I go around the world, where we go to all the different meetings and I am really excited to see where we are going to be using imaging, whether using conventional radiography ultrasound or MRI, imaging plays a significant advancement in our role as rheumatologists. So, again thank you for your time, I also invite you to click on for continued updates and news on scientific data. So Orrin thank you for your time. Thank you Alvin.