Prognoseabschätzung bei früher (rheumatoider) Arthritis – Optimierung durch moderne Bildgebung?

Zusammenfassung

Die Therapie der rheumatoiden Arthritis beginnt für die Patienten mit einer schlechten Prognose heute schon am besten vor der Diagnose, andere Patienten mit der gleichen Diagnose benötigen möglicherweise niemals eine krankheitsmodifizierende Therapie. Klassische Indikatoren für den frühzeitigen Einsatz einer sog. Basistherapie sind die Zahl der geschwollenen Gelenke, die Dauer der Gelenkschwellung, der Nachweis von Rheumafaktoren und/oder CCP-Antikörpern und das Vorhandsein von Erosionen. Die zusammenfassende Bewertung dieser Parameter, z. B. im Visser-Score, erlaubt auch für den Rheumatologen eine gewisse Objektivierung seiner Entscheidung für oder gegen eine Basistherapie bei frühen Verlaufsformen einer Arthritis. In Ergänzung zu den genannten klinischen Parametern ist der initiale Nachweis eines Knochenödems mittels MRT der beste Prädiktor für radiologische Progression. Auch für diese Verlaufbeurteilung sind Ultraschall und MRT wesentlicher sensitiver als sog. Aktivitätsscores. Die Persistenz einer Synovitis und sicher der Nachweis von Knochenödemen bei adäquater Therapie mit klassischen DMARDs könnten Indikation zu einer Therapie mit Biologika sein, deren Effektivität dann auch mittels MRT überprüft werden sollte.

Abstract

In RA patients with a poor prognosis, a disease-modifying antirheumatic therapy should best be started even before diagnosis, in other cases with RA there is no need for such an intervention. Clinical predictors of a poor prognosis are the number of swollen joints, the duration of arthritis, a positive rheumatoid factor and/or positivity for CCP antibodies and erosions in X-ray. The weighted rating of these parameters, e. g., using the Visser score, is of some help to objectify the pro or contra for a therapy with disease-modifying antirheumatic drugs (DMARD). MRI detection of bone oedema provides the best predictor for erosions. In evaluation responses to therapy, MRI as well as arthrosonography are more sensitive than any clinical parameter and should therefore be used to verify remission before tapering DMARDs and to evaluate the efficacy of biologicals.

Schlüsselwörter

Früharthritis - Prognosekriterien - MRT - Knochenödem

Key words

early arthritis - prognostic criteria - MRI - bone oedema

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