Saturday, August 14, 2010

Criteria for Diagnosing Early-Stage RA Published

An estimated 1.3 million Americans have rheumatoid arthritis (RA), and recent evidence suggests that early, aggressive treatment can be important. Prior criteria for diagnosing RA from the American College of Rheumatology (ACR) have been criticized for not detecting early-stage disease processes, delaying treatment in many patients who might benefit, and a newly published approach seeks to remedy these deficiencies.

Reporting in the upcoming September 2010 edition of the journal Arthritis & Rheumatism a joint working group from the ACR and the European League Against Rheumatism (EULAR) developed, in 3 phases, a new approach to classifying RA [Aletaha et al. 2010]. The scheme identifies, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminate between those who are or are not at high risk for developing persistent and/or erosive rheumatoid arthritis. Classification as “definite RA” is based on several factors, including:
  1. Confirmed presence of swelling in at least one joint, indicating synovitis (the inflammation of the synovial membrane that lines a joint),

  2. Absence of an alternative diagnosis, such as lupus or gout, that might better explain the synovitis, and

  3. Achievement of a total score of 6 or greater (out of a possible 10) from the individual scores in 4 domains: (a) number and site of involved joints, (b) serologic abnormality, (c) acute-phase response on CRP (C-reactive protein) and/or ESR (erythrocyte sedimentation rate), and (d) symptom duration.
These new ACR/EULAR criteria for RA present a new approach for identifying patients with a relatively short duration of symptoms who might benefit from early administration of DMARDs (disease-modifying antirheumatic drugs). However, the authors acknowledge that until this diagnostic approach is further validated, it may have greater implications for research trials than everyday clinical practice.

COMMENTARY: In earlier criteria for the classification of RA, developed in 1987, a diagnosis often was not confirmed until the disease was well-advanced and patients exhibited serious joint damage. This new classification system focusing on clinical features at earlier stages could be important for stemming the development persistent and/or erosive disease. At this time, the new criteria may be of most use in allowing researchers to better define individuals as having or not having RA, which will help standardize recruitment into clinical trials and other research studies. It is expected that, with some additional research and possibly modifications, the criteria can be applied in everyday clinical practice. The new diagnostic criteria may facilitate earlier diagnosis and treatment of RA and, as we reported in an UPDATES blogpost last month [here], researchers have stressed that the early and aggressive use of DMARDs can be effective in achieving both short- and long-term disease remission.

REFERENCE: Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid Arthritis Classification Criteria: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis Rheum. 2010(Sep);62(9):2569-2581 [article PDF here].