From the Guidelines
To rule out rheumatoid arthritis (RA), the initial steps should involve referring patients with arthritis to a rheumatologist within 6 weeks after the onset of symptoms, as recommended by the 2016 EULAR guidelines 1. The initial evaluation should include a clinical examination, which is the method of choice for detecting arthritis, and may be confirmed by ultrasonography 1. Key points to consider in the initial steps include:
- Clinical examination to detect arthritis
- Ultrasonography to confirm arthritis
- Consideration of risk factors for persistent and/or erosive disease, including number of swollen joints, acute phase reactants, rheumatoid factor, ACPA, and imaging findings 1
- Early referral to a rheumatologist for patients with persistent symptoms or suspected inflammatory arthritis The goal of these initial steps is to promptly identify patients at risk of persistent arthritis and initiate treatment with disease-modifying antirheumatic drugs (DMARDs) as early as possible, ideally within 3 months, to improve long-term outcomes 1. It is essential to note that the diagnosis of RA relies on a combination of clinical findings and test results, and no single test can definitively rule out the disease. Therefore, a comprehensive approach, including clinical evaluation, laboratory tests, and imaging studies, is necessary to rule out RA and initiate appropriate treatment.
From the Research
Initial Steps for Ruling Out RA
The initial steps for ruling out Rheumatoid Arthritis (RA) involve a combination of clinical evaluation, laboratory tests, and diagnostic criteria.
- The disease should be suspected in patients who present with joint inflammation, especially those who have polyarthritis 2.
- Additional characteristic features include symmetrical small joint polyarthritis, morning stiffness, and constitutional symptoms 2.
- Useful diagnostic tests include inflammatory markers such as C-reactive protein (CRP), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (anti-CCP) antibody 2, 3.
- The combination of RF and anti-CCP antibody has a high sensitivity and specificity for the diagnosis of RA 3.
- CRP is a better measure of disease activity than erythrocyte sedimentation rate (ESR) in some cases, especially when there is discordance between the two tests 4.
Diagnostic Criteria
The diagnosis of RA is based on a combination of clinical and laboratory criteria.
- The American College of Rheumatology and European Alliance of Associations for Rheumatology recommend a treat-to-target approach, including rapid interventions to reduce disease activity and achieve remission 2.
- The Leiden clinical prediction rule for undifferentiated arthritis may facilitate early diagnosis of RA 2.
- Early diagnosis and treatment of RA can avert or substantially slow progression of joint damage in up to 90% of patients, thereby preventing irreversible disability 5.
Laboratory Tests
Laboratory tests play a crucial role in the diagnosis and management of RA.
- CRP, RF, and anti-CCP antibody are commonly used laboratory tests for the diagnosis of RA 2, 3.
- ESR is also used to assess disease activity, but it may be influenced by non-acute phase factors such as immunoglobulins and hemoglobin 4.
- The combination of laboratory tests and clinical evaluation is essential for accurate diagnosis and management of RA 2, 5, 3.