Very recent onset rheumatoid arthritis: clinical and serological patient characteristics associated with radiographic progression over the first years of disease

OBJECTIVES

Despite early recognition and disease modifying anti-rheumatic drug (DMARD) treatment, a sizable proportion of early rheumatoid arthritis (RA) patients show radiological progression. This study was performed to determine the frequency of erosive arthritis and the pace of radiological progression in an inception cohort of patients with very early RA (<or=3 months after onset of symptoms).

METHODS

In order to determine possible prognostic factors for development of erosive disease, we linked the clinical features of these patients to radiological progression in a regression model. About 55 patients with RA and follow-up of at least 3 yrs were analysed. All had complete series of clinical, serological and radiographic assessments. Radiographs were scored according to the Larsen method.

RESULTS

Erosive disease developed in 63.6% of the patients over 3 yrs, with the majority (74.3%) appearing already in the first and 97.2% by the end of the second year. Among all variables available, rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP) first presentation were the most predictive for both development of erosions and the degree of radiological progression. None of the clinical variables at the onset was useful to discriminate between erosive and non-erosive patients. In the final regression model, however, cumulative clinical activity substantially contributed to explaining radiological progression.

CONCLUSION

Despite early treatment, substantial damage occurred in some patients and was associated with presence of strong 'constitutive' predictors such as anti-CCP and RF as well as presence of high long-term clinical disease activity as indicated by C-reactive protein (CRP), swollen joint counts and the absence of a good clinical response (assessed by the failure to achieve lasting low disease activity).

The perception of rheumatoid arthritis core set measures by rheumatologists. Results of a survey

OBJECTIVE

To investigate the perception of values of individual core set measures by rheumatologists, and how it differs across measures and across physicians.

METHODS

We designed a survey in which 44 international expert rheumatologists explicitly marked positions on the scales of seven core-set measures that in their opinion corresponded to cut-points between remission, low, moderate and high disease activity. The measures comprised swollen and tender joint counts (SJC, TJC), CRP, ESR, patient and evaluator global assessments of activity (PGA, EGA), and the Health Assessment Questionnaire Disability Index (HAQ).

RESULTS

The interpretation of measures across physicians was most consistent for ESR and PGA, while for CRP and joint counts there was most variation. Joint counts and CRP implied active disease at lower relative values (using normalized scales) than did PGA, EGA or ESR (P < 0.01 for most comparisons; Bonferroni-adjusted Wilcoxon signed rank test), and most physicians tended to tolerate higher numbers of tender joints than swollen joints to define similar levels of disease activity. Given these cut-points, more RA patients in a typical cross-sectional cohort would be regarded as being in remission according to joint counts (SJC, 35%; TJC, 55%) than to global scores (PGA, 18%; EGA, 9%), and fewer patients would be regarded as being in remission by physician-derived or laboratory measures than by patient-derived ones.

CONCLUSION

These data give insights into the integrative process of activity evaluation and will be informative for future survey designs, studies using physician opinion as the gold standard for criterion validity of disease activity, and allow 'activity mapping' of values on different scales based on expert opinion.

Autoantibody profiling as early diagnostic and prognostic tool for rheumatoid arthritis

BACKGROUND

Early treatment prevents progression of joint damage in rheumatoid arthritis (RA), but diagnosis in early disease is impeded by lack of appropriate diagnostic criteria.

OBJECTIVE

To study the value of rheumatoid factor (RF), anti-cyclic citrullinated peptide autoantibodies (anti-CCP), and anti-RA33 autoantibodies for diagnosis of RA and prediction of outcome in patients with very early arthritis.

METHODS

The prospective follow up inception cohort included 200 patients with very early (<3 months) inflammatory joint disease. Autoantibodies were measured at baseline and analysed in a tree based model which aimed at determining the added diagnostic value of testing for anti-CCP and anti-RA33 as compared with RF alone.

RESULTS

RA was diagnosed in 102 patients, while 98 developed other inflammatory arthropathies. Receiver operator curve analysis showed an optimum cut off level for RF at 50 U/ml, above which anti-CCP and anti-RA33 had no additional diagnostic value. Remarkably, RF >or=50 U/ml and anti-CCP showed similar sensitivity and high specificity for RA, but overlapped considerably. Anti-RA33 was less specific and did not correlate with RF or anti-CCP. Among patients with RA, 72% showed at least one of these three autoantibodies, compared with 15% of non-RA patients. RF >or=50 U/ml and anti-CCP were predictors of erosive disease, whereas anti-RA33 was associated with mild disease.

CONCLUSIONS

Stepwise autoantibody testing in early inflammatory joint disease, starting with RF, followed by anti-CCP (in patients with RF <50 U/ml), and finally anti-RA33, should be used as a sensitive and effective strategy for distinguishing patients with RA at high risk for poor outcome.

Attitudes to early rheumatoid arthritis: changing patterns. Results of a survey

OBJECTIVE

To determine if rheumatologists have changed their views on diagnosis and treatment of early rheumatoid arthritis (RA).

METHODS

Three consecutive questionnaires were sent out to international rheumatologists in 1997, 2000, and 2003. The following aspects of early RA were covered: definition; patient referral time; diagnostic means; follow up intervals; and treatment strategies. All initial participants who responded to at least one of the follow up surveys were included in the analysis.

RESULTS

RA is now defined by a smaller number of affected joints (monarthritis: 9.8% respondents in 1997 v 17.4% in 2003), and shorter symptom duration (<3 months: 65.5% in 1997 v 85.8% in 2003). Early referrals (<6 weeks) increased (8.9% in 1997 v 17.4% in 2003). Serological test for diagnosis was mostly rheumatoid factor (100% in 2003), but anti-CCP was already used by 17.4% in 2003. Follow up of patients with early RA intensified (every 2 weeks: 16.1% in 1997 v 30.4% in 2003; every month: 47.8% in 2003 v 64.3% in 1997). Treatment with disease modifying antirheumatic drugs (DMARDs) mainly comprised methotrexate, sulfasalazine, and antimalarial drugs. Leflunomide was among the two favourite DMARDs of 10.9% in 2003, whereas no biological agent was so. In 2003, 46.7% respondents started treatment with DMARDs if RA was suspected (30.9% in 1997); no one waited for erosions to occur (7.3% in 1997).

CONCLUSION

The data obtained in this study suggest that the concept of diagnosing and treating RA early is accepted by a large proportion of the rheumatological community.

Benefit of very early referral and very early therapy with disease-modifying anti-rheumatic drugs in patients with early rheumatoid arthritis

OBJECTIVE

Delay of disease-modifying anti-rheumatic drug (DMARD) therapy is a major contributing factor for poor outcome in rheumatoid arthritis (RA). Although early therapy has been shown to be particularly effective, there is still uncertainty about the optimal time point of DMARD introduction. We wanted to test if a therapeutic window of opportunity may exist within the first few months of the disease.

METHODS

In this case-control parallel-group study, 20 very early RA (VERA) patients with median disease duration of 3 months were age and gender matched to a group of 20 late early RA (LERA) patients with median disease duration of 12 months until first DMARD initiation. Follow-up time was 36 months. Primary outcome measures were the disease activity score (DAS28) and radiological joint destruction using the Larsen method.

RESULTS

Already after 3 months of DMARD therapy we found a significant difference of improvement in favour of the VERA patients in the DAS28. This trend continued over the study period. At study end the DAS28 showed an improvement of 2.8+/-1.5 in the VERA vs 1.7+/-1.2 in the LERA group (P(c)<0.05). The Larsen scores showed a statistically significant retardation of progression in the VERA compared with the LERA.

CONCLUSION

Our results indicate that there is a window of opportunity for highly successful treatment of RA in the first year, and especially within the first 3 months of therapy. Thus, early diagnosis and therapy may be the crucial step in achieving optimal control of disease progression and prognosis in RA.

Practical progress in realisation of early diagnosis and treatment of patients with suspected rheumatoid arthritis: results from two matched questionnaires within three years

BACKGROUND

Early diagnosis and treatment with disease modifying antirheumatic drugs (DMARDs) have been advocated for patients with rheumatoid arthritis (RA). This survey focuses on the individual definitions and treatment modalities of rheumatologists, and aims at determining the practical realisation of these concepts.

METHODS

A questionnaire to be self completed was handed out at the EULAR Symposium 1997. The main issues dealt with were definition, referral time, diagnosis, follow up, and treatment of early RA. Of the 111 participants, who were from all continents and all age groups, 85 (77%) gave their name and address. In 2000, the same questionnaire was sent to these 85 primary respondents. Forty four questionnaires (52%) were returned, and their results were matched and further evaluated.

RESULTS

The definition of early RA was heterogeneous, but two of three rheumatologists use the term "early" for symptoms shorter than three months. There was a drift towards acceptance of involvement of fewer affected joints. Serological tests obtained for early diagnosis were mostly rheumatoid factor and antinuclear antibodies, usually in combination (approximately 70%), while other tests (antikeratin antibodies, antiperinuclear factor, anti-RA33) were used rarely, but increasingly (21-25% all together). No significant change in the lag time of referral to the specialist of patients with suspected early RA was seen within these three years (<3 months for 50%, >6 months for 20%), while the proportion followed up during the first three months increased. At both times, every second rheumatologist started DMARD treatment only when the 1987 American College of Rheumatology (ACR) criteria were fulfilled. However, in 1997 about 10% were willing to wait for erosions before starting DMARDs, while none did so in 2000. Methotrexate, sulfasalazine, and antimalarial drugs were the most commonly prescribed DMARDs in early RA, with the first two of these still being in increasing use.

CONCLUSION

The understanding of "early" rheumatoid arthritis is heterogeneous, but the vast majority of the rheumatologists surveyed regard symptom duration of <3 months as early. Rheumatoid factor was the most useful laboratory support in early diagnosis. Because there has been no shortening of referral time of patients with new RA within the past three years, and many rheumatologists start DMARDs only when the ACR criteria are fulfilled, it is concluded that guidelines for early referral, as well as for early (rheumatoid) arthritis, are needed.