Quantitative metabolic volumetric product on 18Fluorine-2fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography in assessing treatment response to disease-modifying antirheumatic drugs in rheumatoid arthritis: Multiparametric analysis integrating American college of Rheumatology/European League against Rheumatism criteria

The purpose of this study was to assess the role of fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in the evaluation of treatment response evaluation to disease-modifying antirheumatic drug (DMARD) therapy in patients of rheumatoid arthritis (RA). A total of ten patients with proven diagnosis of RA as per the 2010 American College of Rheumatology/European League against Rheumatism (EULAR) criteria were prospectively evaluated. All patients underwent clinical and biochemical evaluation and a baseline FDG-PET/CT with assessment of maximum standardized uptake value and metabolic volumetric product (MVP) values. DMARD therapy was started with a combination of hydroxychloroquine and sulfasalazine. On follow-up at 3 and 6 months, the response to treatment was assessed by clinical, biochemical, and FDG-PET/CT parameters. These parameters were analyzed in a combined manner, and the patients were grouped into 4 categories as per response to DMARD therapy - complete response, good response, mixed response, and no response. Evaluation of treatment response in ten patients at 3 rd month and in nine patients at 6 months showed (a) agreement for MVP, biochemical parameters with clinical symptomatic assessment in all patients, (b) while agreement for EULAR score was noted in only three patients and disagreement in seven patients with clinical symptoms Response EULAR (rEULAR) (0.37) and at 6 months in only three patients and disagreement in six patients, rEULAR (0.52). The correlation factors at 3 rd month and 6 th months were, respectively, as follows: rMVP (0.67 and 0.75), response RA factor (0.54 and 0.74), response erythrocyte sedimentation rate (0.81 and 0.73), response C-reactive protein (0.78 and 0.51), and response anti-cyclic citrullinated peptide antibodies (0.33 and 0.54). The overall response to DMARD therapy at 3 months was assessed with results showing good response by four cases (40%), mixed response by 1 (10%), no response by 5 (50%), and complete response by none (0%). Step-up therapy at 3 months was initiated in four patients showing nonresponse/progression on clinical symptomatic assessment; of these, two patients showed a good response, one mixed response, and the remaining one continued to show nonresponse at 6 months follow-up. One patient who had a minimal response at 3 months on PET-CT (only 5.96% reduction of MVP) was continued on the same DMARD in view of clinical symptomatic good response (at 3 months) but ultimately had disease progression in all scales and worsening of symptom (at 6 months). FDG-PET/CT-based assessment of inflammatory activity noted in the joints of RA with quantitative parameters can be a promising approach for the whole body assessment of RA disease activity and treatment response assessment, especially in inconclusive cases and correlates well with other parameters. MVP can be used as a useful objective and adjunct parameter for assessing response to treatment.