Title: Does AntiTNF Therapy Alter The Presence Of Foot Symptoms In Patients With Rheumatoid Arthritis
1Does Anti-TNF- Therapy Alter The Presence Of Foot
Symptoms In Patients With Rheumatoid Arthritis?
Catherine J Bowen1, Keith Dewbury3, Madeline
Sampson3, Sally Sawyer2, Sarah P Bennet2, Jane
Burridge1, Christopher J Edwards2,4 and Nigel K
Arden2,4 1.School of Health Professions and
Rehabilitation Sciences, University of
Southampton 2.Department of Rheumatology,
Southampton University Hospitals NHS Trust
3.Department of Radiology, Southampton
University Hospitals NHS Trust 4.MRC
Epidemiology Resource Centre, University of
Southampton. (email cjb5soton.ac.uk)
2Background
- On average it takes about two years for erosion
to develop and be seen on XRay. - Good evidence that US can show both damage to
joints and synovitis earlier than in XRay.
(Wakefield et al 2000, Balint et al 2001) - As soon as there is any soft tissue disease
within the foot the biomechanics become altered. - TNF- inhibition is an effective way of reducing
synovial hypertrophy yet its effect on the foot
is unknown. - The aim of this study was to evaluate the effect
of anti-TNF- therapy on forefoot synovial
hypertrophy (joint and bursal) and foot pain
3Method (N24)
- 24 Consecutive RA patients (ACR criteria)
- Starting anti-TNF-therapy (infliximab,
etanercept, adalimumab) - All assessed for presence of bursitis and
synovitis in the forefoot - Using diagnostic musculoskeletal ultrasound
(MSUS) - At baseline and 12 weeks.
Clinical picture of swollen bursitis of the
plantar forefoot area.
4MSUS scanning
- All participants were scanned according to a
standard protocol by an experienced radiologist - The presence of synovitis of the 2nd and 5th
metatarso-phalangeal joints of both feet and
presence of bursitis within the forefoot was
documented. - All US measurements were recorded by an
experienced radiologist - A Philips HDI 5000 System broadband linear 5 - 12
MHz probe.
5Figure 1. An MSUS image of the left 4th/5th
intermetatarsal space in a healthy adult. The
image is seen from the plantar aspect and was
taken in the transverse plane.
Figure 3 An MSUS image of synovitis within the
left 3rd MTPJ. The image is seen from the dorsal
aspect and was taken in the longitudinal plane.
Figure 4. An MSUS image of synovitis within the
right 5th MTPJ. The image is seen from the
plantaraspect and was taken in the longitudinal
plane.
Figure 2. An MSUS image of bursitis within the
right 4th/5th intermetatarsal space. The image is
seen from the plantar aspect and was taken in the
transverse plane.
6Overview of MSUS Scanning Protocol
7Results Participant demographics
- 24 patients
- 19 female, 5 male
- 9 seronegative, 15 seropositive
- Mean age 59.9 (SD 11.1) years,
- Mean weight 72.5 (16.01) Kg,
- Mean disease duration 11.58 (11.0) years,
- Mean previous number of DMARDs 2.9 (1.4).
8Results Clinical Tests
- At baseline
- mean ESR was 40.6 (25.3),
- Mean CRP 32.9 (26.8),
- Mean DAS28 5.8 (0.9),
- Mean VAS 59.1 (20.7),
- Mean MFPDQ scores 22.5 (9.7).
- At 12 weeks
- mean ESR was 27.1 (16.4),
- Mean CRP 13.2 (15.2),
- Mean DAS28 4.6 (1.4),
- Mean VAS 47.2 (22.3),
- Mean MFPDQ 17.9 (10.0).
9Results Imaging
- At baseline
- Observed presence of bursitis on ultrasound was
noted in 81.25 (39) of feet - Observed presence of synovitis from 48 feet (96
joints) was noted in 64.6 (62 31 right, 31
left)
- At twelve weeks
- Observed presence of bursitis on ultrasound was
noted in 72.9 (35) of feet - Observed presence of synovitis from 48 feet (96
joints) was noted in 53.1 (51 26 right, 25
left)
10Results changes in prevalence of bursitis
synovitis
11Key Results Summary
12Data Analysis
- No significant tendency for changes in the
presence of bursitis or presence of synovitis
between baseline and twelve weeks. - McNemar test
- Significant differences between baseline measures
and twelve weeks were found for - DAS28 (t5.463, plt.0.01),
- CRP (t3.499, plt0.01),
- ESR (t3.575, plt0.01),
- Foot pain and disability (t3.575, plt0.01)
- VAS for wellbeing (t2.541, plt0.05).
13Discussion
- There was a trend towards reduction in the
presence of synovitis and bursitis (greater for
synovitis than bursitis) detected by US within
the forefoot after twelve weeks of
anti-TNF-therapy although the perceived reduction
was not statistically significant. - Significant reductions were observed in clinical
and laboratory assessments of RA disease status
ie. ESR, CRP, DAS28 and MFPDQ. - It may be that the treatment switches off the
disease but twelve weeks is not enough time for
synovial hypertrophy to regress - OR subclinical disease remains longer than
thought as also reported recently by Brown et al
(2006) for the hands.
14Discussion
- In some patients MFPDQ scores (perceived foot
status) improved whilst bursitis counts
increased. - This increase could be attributable to increased
mechanical stress on the forefoot as mobility
improved for those patients. - If this is so then patients on anti-TNF-therapy
would require frequent reassessment of their foot
status and of any interventions such as foot
orthoses and footwear.
15Conclusions
- Findings from this study indicate that forefoot
symptoms associated with inflammation within the
forefoot do reduce after twelve weeks of
anti-TNFa-therapy, although in a minority of
patients these increases. - There are implications for clinical practice, in
particular in the prescription and fitting of
foot orthoses. - Further work is required to determine
associations of the physiological effects of
forefoot inflammation, in particular bursitis,
with mechanical influences during gait. - It would also be useful to determine how often
foot orthotic and footwear interventions should
be reassessed for change in inflammatory status
of the foot?
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17Acknowledgements
- Dr Nigel Arden (Reader Consultant
rheumatologist) - Dr Jane Burridge (Senior Research Fellow)
- Dr Keith Dewbury (Consultant Radiologist)
- The rheumatology nurse specialist team.
- ARC Interns (Mike Backhouse and Lindsey Hooper)