What are the EULAR (European League Against Rheumatism) criteria for diagnosing and treating Rheumatoid Arthritis (RA)?

EULAR Criteria for Rheumatoid Arthritis

The 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis require a score of ≥6/10 points across four domains: joint involvement, serology, acute phase reactants, and symptom duration. 1, 2

Classification Criteria Components

• Target population: Patients with at least one joint with definite clinical synovitis not better explained by another disease 1

• Joint involvement (0-5 points):

  • 1 large joint: 0 points
  • 2-10 large joints: 1 point
  • 1-3 small joints: 2 points
  • 4-10 small joints: 3 points

  • 10 joints (at least 1 small joint): 5 points 1, 3

• Serology (0-3 points):

  • Negative RF and negative ACPA: 0 points
  • Low-positive RF or low-positive ACPA: 2 points
  • High-positive RF or high-positive ACPA: 3 points 1, 2

• Acute phase reactants (0-1 points):

  • Normal CRP and normal ESR: 0 points
  • Abnormal CRP or abnormal ESR: 1 point 1, 3

• Duration of symptoms (0-1 points):

  • <6 weeks: 0 points
  • ≥6 weeks: 1 point 1, 3

• Score interpretation: ≥6/10 points required for definite classification of RA 1, 3

Important Considerations

• Patients with erosive disease typical of RA with compatible history should be classified as having RA regardless of score 1, 4

• These criteria were developed for classification purposes but are frequently used to support diagnosis in clinical practice 2, 5

• The criteria emphasize early identification of patients at risk of developing persistent and erosive disease who would benefit from early DMARD therapy 3, 6

EULAR Treatment Recommendations

• Treatment should begin immediately after RA diagnosis 7

• Treatment target should be sustained remission or low disease activity in every patient 7

• Monitoring should be frequent in active disease (every 1-3 months); if no improvement by 3 months or target not reached by 6 months, therapy should be adjusted 7

• Methotrexate should be part of the first treatment strategy 7

• For patients with contraindications to methotrexate, leflunomide or sulfasalazine should be considered as first-line treatment 7

• Short-term glucocorticoids should be considered when initiating or changing csDMARDs, but should be tapered as rapidly as clinically feasible 7

Disease Activity Assessment

• Disease activity should be measured using validated composite measures including:

  • Disease Activity Score using 28 joint counts (DAS28)
  • Simplified Disease Activity Index (SDAI)
  • Clinical Disease Activity Index (CDAI) 1

• ACR/EULAR remission definition is preferred over DAS28<2.6, which is not considered sufficiently stringent 7

Difficult-to-Treat RA Definition

• All three criteria must be present:
  1. Treatment according to EULAR recommendations and failure of ≥2 b/tsDMARDs with different mechanisms of action after failing csDMARD therapy
  2. Signs of active/progressive disease
  3. Management of signs/symptoms perceived as problematic by rheumatologist and/or patient 7

Clinical Implications

• Early diagnosis and treatment are critical to prevent joint destruction and disability 1, 6

• Regular assessment using composite measures and treat-to-target strategies improve outcomes 1, 6

• Extra-articular manifestations can affect multiple organ systems and contribute to comorbidities including accelerated cardiovascular disease 1