Roy Fleischmann, MD: Are X-Rays Necessary for Treating Rheumatoid Arthritis and Psoriatic Arthritis?

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Roy Fleischmann, MD, examined the necessity of performing repeated x-rays in patients with rheumatic disease as a part of disease management.

In an interview with HCPLive, Roy Fleischmann, MD, Clinical Professor of Medicine at the University of Texas Southwestern Medical Center at Dallas and co-Medical Director of the Metroplex Clinical Research Center in Dallas, examined the necessity of performing repeated x-rays in patients with rheumatoid arthritis and psoriatic arthritis as a part of disease management. He, along with Alvin Wells, MD, PhD, participated in a debate at the 2022 Rheumatology Winter Clinical Symposium in which he opposed conducting x-rays over the course of the disease.

“We know that prior to the development of the advanced therapies, most patients had radiographic progression, which could be extensive, with joint damage,” Fleischmann explained.

However, treatment advancements, such as methotrexate, achieves remission or low disease activity in about 30% of patients, with roughly 60%-70% not exhibiting any x-ray progression. Biologics and targeted synthetics have also worked to decrease radiographic progression in this patient population.

“The key here is treating the patient to remission or low disease activity, which is sustained,” Fleischmann emphasized. “If you do that, then the chances of radiographic progression are really limited.”

In a recently published article, Fleischmann and his team observed over 4 years of therapy in patients treated with upadacitinib or adalimumab and discovered that 85%-90% of patients had no radiographic progression.

“Why should you expose the patient to repeated radiographs?” he asked. “If [a clinician] has any concerns, then they should be performing an ultrasound. If the patient is in sustained clinical remission and they do have some progression, what do you do change them to? There's no data that changing a medication will help that progression.”

He also noted that if a medication is working well for a patient, there is no guarantee that the new medication will work as well or be as well tolerated.

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