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KEY POINTS
■ Research initiatives support an early, aggressive approach to the diagnosis and treatment of rheumatoid arthritis (RA) based on the observation that disease-modifying therapies can prevent long-term joint damage.
■ The 1987 American College of Rheumatology criteria are the accepted standard for diagnosis but are unable to identify persons with early-stage RA (when treatment may do the most good).
■ The new 2010 proposed criteria define definite RA based on the presence of synovitis in at least one joint, the absence of an alternative diagnosis that better explains the presence of synovitis, and a score of 6 or higher out of 10 from individual scores in four domains.
■ Improvements in the delivery of care for patients with new-onset RA can be realized through adoption of the principles of early recognition and management outlined in the newly revised criteria for the diagnosis of RA.
Rheumatoid arthritis (RA) is a systemic inflammatory disease resulting in polyarthritis. Joint manifestations typically include pain, swelling, stiffness, and functional limitations. Two of the most important factors contributing to a poor prognosis in patients with RA are a delay in diagnosis and a delay in initiating treatment with disease-modifying antirheumatic drugs (DMARDs). Both factors are greatly impacted by a delay in referring the patient to a rheumatologist. Recognizing the signs and symptoms of early RA is imperative so that the window of opportunity for treatment that has the best chance to minimize disability and optimize outcome is not missed.
Research initiatives support an early, aggressive approach to the diagnosis and treatment of RA based on the observation that DMARDs can prevent long-term joint damage (Figure 1). Early intervention is critically important because RA can progress rapidly and damage joints even in its early stages.1 Because of this, the goal of therapy has shifted to providing earlier treatment of RA.
The term early RA is not well-defined in the literature, which has resulted in an urgency within the rheumatologic community to look at alternative measures to assist in the early detection of this disease. Concern has grown that the 1987 American College of Rheumatology (ACR) diagnostic criteria for RA lack sensitivity in identifying early-stage
disease. Many patients presenting with early RA do not meet the 1987 criteria until their disease is more advanced. As a result, these patients are not recognized as having RA, and disease-
modifying agents are not started until much later in the course of their disease.
With the current barriers to early diagnosis of RA, generalist clinicians must develop the skills necessary to identify early disease so that rheumatologic referral can be made in a timely manner. In September 2010, proposed changes to the 1987 criteria were published.2 The revised criteria resulted from collaboration between the ACR and the European League Against Rheumatism (EULAR) in order to more clearly define RA. These changes address the limitations of the 1987 ACR classification criteria to promote earlier diagnosis of RA and to differentiate it from other inflammatory joint conditions.2
BACKGROUND
Rheumatoid arthritis is characterized by inflammatory arthritis that involves multiple joints. Often RA begins gradually and affects the small joints of the hands, wrists, and feet before moving to larger joints. According to the CDC, the prevalence of RA in the United States is approximately 1%, and it constitutes the most common form of chronic inflammatory arthritis.3 If not appropriately managed, RA can lead to substantial physical disability and even to premature death.4 If their condition is left untreated, 20% to 30% of patients with new-onset RA become permanently work-disabled within 2 to 3 years, making RA a major public health concern.5
The initial course of RA is known to involve a lag time of several months between the onset of symptoms and diagnosis. This lag time is due to delay between the onset of symptoms and the first medical encounter and further delay between the first medical encounter and diagnosis. In a review of medical records from a health maintenance organization in central Massachusetts, Chan and colleagues evaluated 81 patients who received a new diagnosis of RA between 1987 and 1990.6 This review demonstrated that the average time between initial presentation for evaluation of joint pain to confirmation of a diagnosis of RA was 18 weeks.6
In a prospective follow-up study performed by Fex and colleagues, 113 patients with definite RA and mean disease duration of 11.4 months were followed prospectively over 5 years.7 Radiographs of the hands and feet were obtained annually during the study period. Findings revealed that radiologic damage is significantly progressive during the first 5 years following the onset of joint pain, with the rate of progression being most prominent within the first
2 years.7
Since 1987, new therapies for RA have emerged that have been shown to control synovitis and to slow, or even stop, radiographic progression of joint damage.8 Over the past decade, the optimal use of DMARDs and the availability of new biologic agents have enhanced RA management. Additionally, the longer active disease persists without being treated, the less likely the patient is to respond to therapy.9 These findings, as well as evidence confirming early joint damage in the disease course, have emphasized the importance of early intervention. As such, the goal of therapy has shifted to providing earlier treatment to prevent long-term joint damage.