The study was approved by local Institutional Review Board for the Protection of Human Subjects. No patients were excluded from the screening protocol. Patients were included if they had any joint symptoms between the stated dates, regardless of prior patient diagnosis, and if they consented to the study. A total of 126 new and established consecutive patients were recruited after being screened by their primary rheumatologist. The investigators screened patients one day a week, at the New York University Hospital for Joint Diseases between 1 August 2010 and 30 April 2011. Patients were evaluated during their usual care in a general rheumatology private practice of seven rheumatologists at a university setting. The objective of this study, therefore, is to test the validity of the new 2010 ACR/EULAR RA criteria prospectively in a general rheumatology practice to determine how well it can distinguish RA from other types of inflammatory arthritis. The 2010 classification criteria may also similarly be adapted into a diagnostic criteria by practising physicians as the 1987 criteria have been and the appropriateness of its use should be addressed. 9 Likewise, many patients who present with early undifferentiated arthritis may go on to develop into other diseases and it must be determined whether the criteria have the ability to distinguish among them. It therefore becomes necessary to test a diagnostic tool in a broad spectrum of patients, including a control population of non-RA rheumatic conditions, in order to be appropriately validated.
Illnesses such as systemic lupus erythematosus (SLE), psoriatic arthritis (PsA) and osteoarthritis (OA), can present with inflammatory joints and positive laboratory testing results that may imitate RA on a scoring system. This was not part of the criteria development process, a major shortcoming in our opinion.
It is, however, not yet known how these criteria for the classification of RA perform to identify RA in patients with arthritis seen in routine clinical care as well as in patients with other conditions that may mimic RA. Many inflammatory conditions have overlapping and similar symptoms, and classification criteria need to demonstrate that they can differentiate among these conditions to be really useful in identifying the ‘true’ RA patients. 6 This is an interesting statement as, if all other possible causes were so simple to identify and eliminate, we would not need criteria for RA as that would be the only diagnostic option left to the clinician. The new RA classification criteria state that, as a prerequisite, a patient needs to have a swollen joint and ‘…all other possible diagnosis have been eliminated’. 6–8 Patients who would benefit from rapid initiation of methotrexate therapy are targeted using the new criteria. The new 2010 ACR/EULAR (European League Against Rheumatism) criteria for RA have been designed to classify patients with early RA in order to better study this group of patients. 4 Especially, rheumatoid nodules and radiographic findings are rare in early disease, in addition to less symmetric disease early on in the course of RA. 5 However, these criteria have been shown to have a low sensitivity for targeting early arthritis and will therefore miss the crucial population in which disease progression can be halted. Previously, the American College of Rheumatology (ACR) 1987 RA criteria 4 have been used to classify patients as RA for participating in studies and it also extended into clinical practice for diagnostic purposes. Therefore, it is necessary to have the ability to classify patients early in their RA course in order to investigate new and appropriate treatments and treat them early in every day clinical care. Achieving remission seems most likely, if the inflammatory burden is turned off as soon as after symptoms start also the amount of time a patient spends in remission is likely determined by how early this response was achieved.
Ongoing trials are constantly searching for novel therapeutic targets to treat this debilitating disease with the aim to further improve the long-term outcome for our RA patients. 1 Early treatment impacts long-term clinical improvements 2 3 and early and aggressive treatment of RA has revolutionised our approach to how we use our current medications. Rheumatoid arthritis (RA) affects 1% of the population and leads to the progressive disability and joint destruction if not diagnosed and treated early.
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