SMALL JOINT SYNOVITIS IN RHEUMATOID-ARTHRITIS - SHOULD IT BE ASSESSEDSEPARATELY

In the assessment of disease activity in rheumatoid arthritis (RA) sma ll joint synovitis is traditionally included only as a component of ac tive, tender or swollen joint counts. By contrast, in the assessment o f disease damage in RA, the X-ray score of hands and feet represents o ne of the most common parameters used and is regarded as a major indic ator of outcome. Data presented in this study lead us to hypothesize t hat the small joints require separate assessment in any study of disea se activity or outcome in RA: (i) there is clear evidence that small j oint synovitis often occurs in the absence of an abnormal acute phase response (ESR or C-reactive protein) and (ii) measured synovitis is an individual (PIP) joint has been shown to be reliable and to be relate d to subsequent X-ray changes in the same joint. Our findings show tha t, in a study of a treatment of RA, it is quite possible for disease a ctivity measures to appear controlled while inflammation continues in the small joints causing radiological damage. This radiological damage is reflected as an adverse outcome. Hence the paradox of improving di sease activity but not outcome. We argue that small joint inflammation and damage should be recognized as one aspect of the RA disease proce ss offering unique information and as such should be assessed independ ently.