New criteria for diagnosing rheumatoid arthritis—introduced last October and expected in print later this year—should lead to earlier diagnoses, easier insurance coverage for treatment, and improved patient outcomes, agreed many rheumatologists. The new criteria are also likely to be adopted fairly quickly by most U.S. rheumatologists, experts added.
“It's a paradigm shift: Prevent disease or significantly abrogate it if rheumatoid arthritis is caught early. If you wait for the 1987 criteria to be fulfilled, patients will have established disease. Our goal is to identify and treat patients as early as possible,” said Dr. Clifton O. Bingham III, associate director of the Johns Hopkins Arthritis Center in Baltimore and a member of the panel that came up with the new RA criteria.
A panel of 22 rheumatologists formed by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) worked for 3 years to devise new RA diagnostic criteria to replace the existing RA classification criteria that were released by the ACR in 1987 (Arthritis Rheum. 1988;31:315-24). An initial public report on the new diagnostic criteria occurred last October at the annual meeting of the ACR in Philadelphia. (See box.) A peer-reviewed, written version of the criteria, as well as reports on the multistage process that led to their creation, should be published later this year, said Dr. Gillian A. Hawker, chief of medicine at Women's College Hospital in Toronto and a project leader.
Although the U.S. rheumatologists who were interviewed for this article weren't completely uniform in their expectations of how the new criteria will likely affect practice, most agreed on several broad consequences, starting with the way by which the new criteria will change the timing of RA diagnosis and treatment.
“This will lead to earlier, definitive assessment and treatment of patients with RA. A major weakness of the previous classification criteria is that they included a bad outcome [and] erosions, and required more extensive disease. We want to treat patients before erosions occur,” said Dr. Eric L. Matteson, professor and chairman of rheumatology at the Mayo Clinic in Rochester, Minn.
“These criteria should help clinicians diagnose patients at an earlier stage, and possibly lead to earlier treatment as well, thereby improving outcomes. They may help qualify patients for therapy at an earlier stage of their disease,” said Dr. Arthur F. Kavanaugh, professor of medicine at the University of California, San Diego.
A major way in which the new criteria enable earlier diagnosis is by setting a lower threshold for the number of involved joints, noted Dr. Michael E. Weinblatt, professor of medicine at Harvard Medical School and associate director of the center for arthritis and joint diseases at Brigham and Women's Hospital, both in Boston. “A lot of times patients don't seek care or don't get referred because only a couple of joints are involved.” The new criteria make it clear that “a couple of joints could be RA.”
These criteria “will allow for earlier diagnosis, but there is a great deal of clinical judgment [involved], and I've certainly diagnosed RA in many patients who did not fulfill the [1987] ACR criteria,” said Dr. Daniel Furst, professor of medicine at the University of California, Los Angeles. “What this does is codify and validate the fact that we make diagnoses earlier” than the old classification criteria allowed. Now rheumatologists and even primary care physicians “will feel comfortable making an earlier diagnosis,” he said.
Earlier diagnosis was a major goal of the panel that came up with the new diagnostic criteria, based on an “increasing concern that we were missing patients with aggressive, erosive disease,” said Dr. Philip J. Mease, a member of the panel and a rheumatologist at Swedish Hospital Medical Center in Seattle. “I'm not sure that the criteria will identify more patients, but they will more precisely identify patients who will have an aggressive course. The hope is that if you start treatment [of these patients] sooner, you may prevent disease progression.”
Experts were split on how confident they were that earlier diagnosis and treatment would lead to better outcomes, although that's what they generally expect.
“We hope it leads to better outcomes. That's the underlying assumption,” Dr. Furst said.
“Earlier treatment of RA means better outcomes, including less irreversible damage,” Dr. Matteson said.
Dr. Mease said that some evidence already exists for improved outcomes from early treatment. He cited results from studies such as TICORA (Tight Control for Rheumatoid Arthritis) (Lancet 2004;364:263-9), BeSt (Behandel-Strategieën) (Arthritis Rheum. 2005:52:3381-90), and CAMERA (Computer-Assisted Management of Early Rheumatoid Arthritis) (Ann. Rheum. Dis. 2007;66:1443-9). Results from all three studies showed that aggressive treatment early in RA led to better outcomes, with lower joint counts, better function, and more significant inhibition of radiologic damage, Dr. Mease said in an interview.