In Rheumatoid Arthritis, the Same Joints Tend to be Affected by Swelling Over Time

If you have rheumatoid arthritis (RA), you likely have ample experience with swollen joints. What you might not realize is that the same joints might swell repeatedly, even if your doctor is using a treat-to-target approach.

Treat-to-target is a medical strategy in which you doctor treats your RA as aggressively as needed to reach a specific, predetermined goal. Often, the goal is remission or low disease activity — and it’s possible to reach that goal while having some mildly swollen joints that aren’t bothersome or obvious but that could indicate joint damage is progressing.

As part of evaluating your progress toward the goal, doctors will likely asses your joints for inflammation. But are certain treat-to-target strategies better at minimizing joint inflammation than others? Specifically, can they minimize recurrent joint inflammation?

A new study, published in the Annals of the Rheumatic Diseases, looked at whether joint swelling recurs in the same joints over time in RA patients using a treat-to-target approach. The study assessed more than 500 RA patients in the Netherlands who were undergoing different treat-to-target approaches including:

• Sequential monotherapy (taking one medication at a time)
• Step-up combination therapy starting with methotrexate (taking MTX with other medications; escalating treatment as needed)
• Initial combination therapy with methotrexate, sulfasalazine, and prednisone
• Initial combination therapy with methotrexate and infliximab (Remicade).

All patients were assessed for swelling in 68 joints every three months for about a decade.

As expected, disease activity and swollen joint count often shifted from visit to visit, which makes sense given that treat-to-target was being employed. What was interesting, however, was that swelling in same joints tended to recur after symptoms abated.

“In 46 percent of the joints that were swollen at baseline, joint swelling later recurred at least once during follow-up,” the authors wrote, adding that this is the first study to show that “joint swelling in RA tends to recur in the same joints over time.”

RA is associated with excess inflammation throughout your body, and systemic therapy like pills and infusions are designed to bring those levels of inflammation down. Although those full-body treatments are certainly effective for reducing overall disease activity, the fact that the same joints tend to swell over and over suggest that there are some local factors (at a joint site) also involved in RA.

For patients, the main takeaway is that you and your doctor might need to closely monitor joints that have been swollen in the past, even if your overall disease activity seems to be low. That might include imaging tests like MRIs, which could reveal damage in a joint even if swelling in that joint is not obvious during a checkup. (Ask your doctor if this is advisable.)

These findings also indicate that both local and systemic treatment might be needed to prevent serious joint damage. Unfortunately, it’s not clear whether currently available local treatments, like steroid injections, will do more than temporarily relieve symptoms.

“The recurrence of signs and symptoms after injections may indicate that more effective local therapies need to be investigated or developed,” the researchers wrote. They suggested that “more effective local therapies need to be investigated or developed.”

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