Over the years, evidence has accumulated suggesting that aggressive treatment for early rheumatoid arthritis is essential, while delayed treatment has consequences. Early recognition of the disease has been linked with successful treatment outcomes.
DMARDs Slow Progression of Rheumatoid Arthritis
When we refer to successful treatment outcomes for early rheumatoid arthritis, the discussion moves beyond pain management with analgesic medications or anti-inflammatory medications such as nonsteroidal anti-inflammatory medications (NSAIDs). It's a reference to disease-modifying drugs (DMARDs), such as (methotrexate) or the biologic drugs. Disease-modifying drugs attempt to slam the door on disease progression, from joint damage to systemic involvement. Without successful disease-modifying treatment, there is decreased joint function, as well as increased disability, morbidity and mortality.
When researchers speak of early rheumatoid arthritis, they are referring to a window of opportunity to treat and to achieve the successful outcomes that are the goals of disease-modifying treatment. When patients hear about early rheumatoid arthritis, they understand it's essentially "the earlier, the better" - and they wonder, of course, were they early enough. The question for patients becomes, what exactly defines early rheumatoid arthritis?
Classification of Rheumatoid Arthritis
The American College of Rheumatology (ACR) suggests that patients who have at least one joint with clinical synovitis (swelling) or who have synovitis not better explained by another disease should be tested for rheumatoid arthritis. The ACR also has established classification criteria for rheumatoid arthritis (a score-based algorithm). After adding the score from categories A-D, a score of six out of 10 determines rheumatoid arthritis.
A. Joint involvement:
1 large joint (score=0)
2-10 large joints (score=1)
1-3 small joints with or without involvement of large joints (score=2)
4-10 small joints with or without involvement of large joints (score=3)
10 joints with at least 1 small joint (score=5)
B. Serology (at least 1 test result is needed for classification):
Negative rheumatoid factor (RF) and negative anti-citrullinated protein antibody (ACPA) (score=0)
Low-positive RF or low-positive ACPA (score=2)
High-positive RF or high-positive ACPA (score=3)
C. Acute-phase reactants (at least one test result is needed for classification):
Normal CRP (C-reactive protein) and normal ESR (sedrate) (score=0)
Abnormal CRP or abnormal ESR (score=1)
D. Duration of symptoms:
less than 6 weeks (score=0)
greater than or equal to 6 weeks (score=1)
What It All Means to You
There are studies for early rheumatoid arthritis that require at least six to 12 weeks of symptoms for a patient to be included. But diagnostic criteria or criteria for inclusion in a clinical research trial do not define when a patient should be treated. It has been suggested that treatment should depend on the severity and persistence of a patient's symptoms and not be bound by time constraints of stated criteria.
It has been suggested that a patient with symptoms that persist for six weeks or more but less than six months should be referred to a rheumatologist for evaluation. That may be what we consider "early rheumatoid arthritis". It also has been suggested that patients with symmetric (same joint on both sides of the body) joint symptoms that last for more than 6 months are likely to develop chronic, persistent rheumatoid arthritis.
Sources:
Rheumatoid Arthritis: Early Diagnosis and Treatment. Chapter 6 - Diagnosis of Early Rheumatoid Arthritis. Cush, Weinblatt, and Kavanaugh. Third Edition.
2010 Rheumatoid Arthritis Classification Criteria. Arthritis & Rheumatism. Vol. 62, No. 9, September 2010, pp 2569–2581
http://www.rheumatology.org/practice/clinical/classification/ra/2010_revised_criteria_classification_ra.pdf
