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One of the most difficult task in clinical medicine is to
evaluate a patient who presents with joint pain. If
you were to open the index of a rheumatology text
you would find a list of over hundred different types
of arthritides (Table I). Fortunately the more
commonly seen musculoskeletal conditions can be
divided into five different groups. If approached
logically a working diagnosis can usually be easily
obtained.
EDITORIAL
Early Diagnoses of Rheumatoid Arthritis is Important. It should
be Clinical not Lab Dependent
Asim Zulfiqar
-------------------------------------------------
Correspondence:
Prof. Dr. Asim Zulfiqar
Professor of Medicine
Islamic International Medical College
Riphah International University Islamabad
E-mail: asimzulfiqar786@gmail.com
Received: February 15, 2016; Accepted: March 06, 2016
window of therapeutic opportunity (a time span in
which the institution of effective therapeutic
strategy in the form of DMARDs and biologicals) is
important to modify the course of disease
significantly, decelerating the progression of disease
and minimizing joint damage and disability. Early
diagnosis of RA is important as early therapeutic
intervention reduces the accrual of joint damage and
3
disability.
In the first decade of current century the
classification criteria set that was in widespread
international use to define RA were the 1987 ACR
4
(American college of rheumatology) criteria. Those
criteria gave emphasis to serological tests,
rheumatoid nodules and joint erosions which are
actually late features of disease. In fact these late
features of disease which are pathognomonic for the
diagnosis of RA can be prevented if effective therapy
is given in early phase of the disease. Keeping in view
the problems in diagnosing ERA the working group
developed ACR/EULAR classification criteria for RA in
5
2010. These classification criteria were introduced
to select amongst the newly presenting patients with
undifferentiated inflammatory synovitis, the subset
of patients who are at sufficiently high risk of
persistent and/or erosive disease (this being the
appropriate current paradigm underlying the
disease construct RA).
These classification criteria can be applied to any
patient or otherwise healthy individual as long as
two mandatory requirements are met. First there
must be evidence of currently active synovitis in at
least one joint. Secondly the criteria must be applied
to those patients in whom the observed synovitis is
not better explained by another diagnosis. Four
additional criteria (Table II) can then be applied to
eligible patients to identify definite RA. Application
of these criteria provides a score from 0 to 10 with
score of 6 or >6 being indicative of RA. A patient with
a score<6 cannot be classified as having definitive RA
at the moment but might fulfill the criteria at a later
time point. To classify a patient as having definite RA
or not a history of symptom duration, a thorough
joint evaluation of both small and large joints and at
least one serological test (RF or ACPA) and one acute
phase response measure (ESR/CRP) must be
obtained. It is acknowledged that an individual
Table I: Simple classificaon of Arthric and Rheumac
1
Disorders
One of the most common and devastating disease
that has been encountered in clinical medicine
practice is rheumatoid arthritis (RA). RA is a chronic
inflammatory disease characterized by joint
swelling, joint tenderness and destruction of
synovial joints leading to severe disability and
2
premature mortality. RA affects between 0.5-1% of
the general population, mainly during their working
age affecting thus the functional capacity, with great
economic burden to the individual and the society. In
the last decades there was a clear evolution in
knowledge about pathophysiology of the disease
resulting in its approach and treatment. The
association between symptom duration and RA
persistence is not linear suggesting the presence of a
confined period in which RA is most susceptible to
treatment. Early RA (ERA) is defined as the diagnosis
given in the first weeks or months of joint symptoms
or signs. The concept of ERA and existence of a patient may meet the definition of RA without
requiring lab test or even if the serological tests are
negative (seronegative RA) e.g. patients with a
sufficient number of joints and longer duration (> 6
weeks) of symptoms will achieve 6 points regardless
of their serological or acute phase response status.
In conclusion RA is entirely a clinical diagnosis.
Presence of positive serology (RF/ACPA) may potentiate your clinical diagnosis of RA but the
presence of characteristic pattern of joint
involvement of greater than six weeks duration
almost makes certain the diagnosis of ERA. A due
consideration of early aggressive treatment should
be made in such patients to arrest the progressive
disease at an earlier stage.
Asim Zulfiqar. (2016) Early Diagnoses of Rheumatoid Arthritis is Important. It should be Clinical not Lab Dependent, , Volume-11, Issue-1.
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