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Findings from the TREAT EARLIER trial suggest that MRI-detected multisite inflammation, particularly tenosynovitis with osteitis, helps identify patients with clinically suspect arthralgia who are more likely to benefit from early methotrexate treatment.
Clinically suspect arthralgia (CSA) represents a stage in which patients have symptoms suggestive of rheumatoid arthritis (RA), but do not yet have clinically detectable arthritis. Magnetic resonance imaging (MRI) can reveal inflammation that remains hidden on physical examination, including synovitis, tenosynovitis, and osteitis. Identifying which patients with this subclinical inflammation are most likely to respond to treatment could help move early RA management towards a more personalised approach.
Researchers examined 115 patients with CSA and MRI-detected subclinical inflammation who received an intramuscular glucocorticoid injection and methotrexate for 1 year. Rather than assessing symptoms alone, they looked for a meaningful reduction in MRI-detected synovitis, tenosynovitis, or osteitis after treatment. Of 115 treated patients, 44 (38%) attained an MRI-defined treatment response after 12 months. Responders also experienced meaningful improvements in symptoms and physical function:
Importantly, baseline clinical characteristics were not independently linked with treatment response. Instead, the severity and distribution of subclinical joint inflammation on MRI emerged as the key differentiating factor. Tenosynovitis and osteitis were particularly predictive. Those with:
The predictive performance was comparable in both anti-citrullinated protein antibody (ACPA)-positive and ACPA-negative patients who were at heightened risk of RA. The findings suggest that the burden of subclinical inflammation—not simply the presence of arthralgia—may help identify those who derive the greatest benefit from methotrexate. In particular, multisite tenosynovitis, with or without osteitis, appears to define a subgroup of CSA patients with a high likelihood of MRI-detectable treatment response. These findings could help advance personalized strategies for arthralgia at risk of RA, although further validation is needed prior to imaging-based selection can routinely guide preventive therapy.
RMD Open
Which arthralgia patients benefit most in reduction of subclinical joint inflammation by methotrexate treatment: results from the TREAT EARLIER trial
Stijn Claassen et al.
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