Revision to the musculoskeletal domain of the BILAG-2004 index to incorporate ultrasound findings

Abstract

Objectives
To improve the definitions of inflammatory arthritis within the musculoskeletal (MSK) domain of the BILAG-2004 index by incorporating imaging findings and clinical features predictive of response to treatment.

Methods
The BILAG MSK Subcommittee proposed revisions to the BILAG-2004 index definitions of inflammatory arthritis, based on review of evidence in two recent studies. Data from these studies were pooled and analysed to determine the impact of the proposed changes on the severity grading of inflammatory arthritis

Results
The revised definition for severe inflammatory arthritis includes definition of “basic activities of daily living”. For moderate inflammatory arthritis, it now includes synovitis, defined by either observed joint swelling or MSK ultrasound evidence of inflammation in joints and surrounding structures. For mild inflammatory arthritis, the definition now includes reference to symmetrical distribution of affected joints and guidance on how ultrasound may help re-classify patients as moderate or no inflammatory arthritis.

Data from two recent SLE trials were analysed (219 patients). 119 (54.3%) were graded as having mild inflammatory arthritis (BILAG-2004 C). Of these, 53 (44.5%) had evidence of joint inflammation (synovitis or tenosynovitis) on ultrasound. Applying the new definition increased the number of patients classified as moderate inflammatory arthritis from 72 (32.9%) to 125 (57.1%), while patients with normal ultrasound (n = 66/119) could be recategorised as BILAG-2004 D (inactive disease).

Conclusions
Proposed changes to the definitions of inflammatory arthritis in the BILAG 2004 index will result in more accurate classification of patients who are more or less likely to respond to treatment.