Purpose of review: To provide an update on new concepts in the inhibition of radiographic progression with current and emerging biologic therapy.
Recent findings: The advent of biologic therapies for the treatment of rheumatoid arthritis has given rise to the concept of a disconnect between clinical and radiographic outcomes. Radiographic progression has been observed in patients in clinical remission, whereas inhibition of radiographic progression has been demonstrated in patients with clinically active disease. Moreover, imaging remission has been shown to be much easier to achieve than clinical remission. Biologics are superior to methotrexate (MTX) in inhibiting radiographic progression at every level of disease activity and response. The majority of patients receiving biologics and a significant proportion receiving MTX alone do not progress radiographically. The combination of a biologic and MTX inhibits radiographic progression more than either alone, reducing both the proportion of patients progressing and the degree of progression of those who do progress. Although biologics are similar in their ability to inhibit radiographic progression in most patients, they differ in inhibiting the progression in the rapid radiographic progressors.
Summary: The disconnect between clinical and radiographic outcomes demonstrated with biologics implies the need to monitor both outcomes in order to treat patients most effectively. The superiority of biologics over MTX in inhibiting radiographic progression suggests that the clinical target for a biologic may differ from that for MTX to prevent structural damage and preserve function. For most patients, radiographic inhibition should not affect the choice of a biologic.