Abstract
Objective: To develop a referral recommendation that may serve as a clinical guide for primary care doctors, enabling them to identify patients with suspected RA during the early inflammatory stages.
Methods: Key points of the referral criteria were formed based on a thorough literature review targeting early RA, early arthritis clinics, DMARD treatment for early RA, prognostic factors of disease progression, early RA clinical trials, and quality of life. Evidence was graded using the methods defined by Shekelle et al. A draft version of the criterion was circulated among the authors for critical evaluation. A consensus integrated these comments.
Results: Clinical evidence strongly supports the observations that structural damage occurs early in active RA and that early DMARD treatment improves the long term outcome of the disease. The observations indicate that rapid referral to a rheumatologist is advised when RA is suspected. This may be supported by the presence of any of the following: ≥3 swollen joints, metatarsophalangeal/metacarpophalangeal involvement, and morning stiffness of ≥30 minutes.
Conclusion: The proposed early referral recommendation is a viable tool for primary care doctors to identify potential patients with active RA early in the disease. Early referral to a rheumatologist for definitive diagnosis and early DMARD treatment should improve the long term outcome of RA.
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Figure 1 .
Early referral algorithm for newly diagnosed RA.
Selected References
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- Abu-Shakra M., Toker R., Flusser D., Flusser G., Friger M., Sukenik S., Buskila D. Clinical and radiographic outcomes of rheumatoid arthritis patients not treated with disease-modifying drugs. Arthritis Rheum. 1998 Jul;41(7):1190–1195. doi: 10.1002/1529-0131(199807)41:7<1190::AID-ART7>3.0.CO;2-B. [DOI] [PubMed] [Google Scholar]
- Anderson J. J., Chernoff M. C. Sensitivity to change of rheumatoid arthritis clinical trial outcome measures. J Rheumatol. 1993 Mar;20(3):535–537. [PubMed] [Google Scholar]
- Anderson J. J., Wells G., Verhoeven A. C., Felson D. T. Factors predicting response to treatment in rheumatoid arthritis: the importance of disease duration. Arthritis Rheum. 2000 Jan;43(1):22–29. doi: 10.1002/1529-0131(200001)43:1<22::AID-ANR4>3.0.CO;2-9. [DOI] [PubMed] [Google Scholar]
- Arnett F. C., Edworthy S. M., Bloch D. A., McShane D. J., Fries J. F., Cooper N. S., Healey L. A., Kaplan S. R., Liang M. H., Luthra H. S. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315–324. doi: 10.1002/art.1780310302. [DOI] [PubMed] [Google Scholar]
- Backhaus M., Kamradt T., Sandrock D., Loreck D., Fritz J., Wolf K. J., Raber H., Hamm B., Burmester G. R., Bollow M. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum. 1999 Jun;42(6):1232–1245. doi: 10.1002/1529-0131(199906)42:6<1232::AID-ANR21>3.0.CO;2-3. [DOI] [PubMed] [Google Scholar]
- Borg G., Allander E., Lund B., Berg E., Brodin U., Pettersson H., Trang L. Auranofin improves outcome in early rheumatoid arthritis. Results from a 2-year, double blind placebo controlled study. J Rheumatol. 1988 Dec;15(12):1747–1754. [PubMed] [Google Scholar]
- Brennan P., Harrison B., Barrett E., Chakravarty K., Scott D., Silman A., Symmons D. A simple algorithm to predict the development of radiological erosions in patients with early rheumatoid arthritis: prospective cohort study. BMJ. 1996 Aug 24;313(7055):471–476. doi: 10.1136/bmj.313.7055.471. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Buckland-Wright J. C., Clarke G. S., Chikanza I. C., Grahame R. Quantitative microfocal radiography detects changes in erosion area in patients with early rheumatoid arthritis treated with myocrisine. J Rheumatol. 1993 Feb;20(2):243–247. [PubMed] [Google Scholar]
- Buckley C. D. Science, medicine, and the future. Treatment of rheumatoid arthritis. BMJ. 1997 Jul 26;315(7102):236–238. doi: 10.1136/bmj.315.7102.236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Callahan L. F. The burden of rheumatoid arthritis: facts and figures. J Rheumatol Suppl. 1998 Jul;53:8–12. [PubMed] [Google Scholar]
- Chan K. W., Felson D. T., Yood R. A., Walker A. M. The lag time between onset of symptoms and diagnosis of rheumatoid arthritis. Arthritis Rheum. 1994 Jun;37(6):814–820. doi: 10.1002/art.1780370606. [DOI] [PubMed] [Google Scholar]
- Combe B., Dougados M., Goupille P., Cantagrel A., Eliaou J. F., Sibilia J., Meyer O., Sany J., Daurès J. P., Dubois A. Prognostic factors for radiographic damage in early rheumatoid arthritis: a multiparameter prospective study. Arthritis Rheum. 2001 Aug;44(8):1736–1743. doi: 10.1002/1529-0131(200108)44:8<1736::AID-ART308>3.0.CO;2-I. [DOI] [PubMed] [Google Scholar]
- Criswell L. A., Such C. L., Yelin E. H. Differences in the use of second-line agents and prednisone for treatment of rheumatoid arthritis by rheumatologists and non-rheumatologists. J Rheumatol. 1997 Dec;24(12):2283–2290. [PubMed] [Google Scholar]
- Davis M. J., Dawes P. T., Fowler P. D., Clarke S., Fisher J., Shadforth M. F. Should disease-modifying agents be used in mild rheumatoid arthritis? Br J Rheumatol. 1991 Dec;30(6):451–454. doi: 10.1093/rheumatology/30.6.451. [DOI] [PubMed] [Google Scholar]
- Deodhar A. A., Brabyn J., Jones P. W., Davis M. J., Woolf A. D. Longitudinal study of hand bone densitometry in rheumatoid arthritis. Arthritis Rheum. 1995 Sep;38(9):1204–1210. doi: 10.1002/art.1780380905. [DOI] [PubMed] [Google Scholar]
- Devlin J., Lilley J., Gough A., Huissoon A., Holder R., Reece R., Perkins P., Emery P. Clinical associations of dual-energy X-ray absorptiometry measurement of hand bone mass in rheumatoid arthritis. Br J Rheumatol. 1996 Dec;35(12):1256–1262. doi: 10.1093/rheumatology/35.12.1256. [DOI] [PubMed] [Google Scholar]
- Drossaers-Bakker K. W., de Buck M., van Zeben D., Zwinderman A. H., Breedveld F. C., Hazes J. M. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arthritis Rheum. 1999 Sep;42(9):1854–1860. doi: 10.1002/1529-0131(199909)42:9<1854::AID-ANR9>3.0.CO;2-F. [DOI] [PubMed] [Google Scholar]
- Eberhardt K., Fex E. Clinical course and remission rate in patients with early rheumatoid arthritis: relationship to outcome after 5 years. Br J Rheumatol. 1998 Dec;37(12):1324–1329. doi: 10.1093/rheumatology/37.12.1324. [DOI] [PubMed] [Google Scholar]
- Edworthy S. M. Morning stiffness: sharpening an old saw? J Rheumatol. 1999 May;26(5):1015–1017. [PubMed] [Google Scholar]
- Egsmose C., Lund B., Borg G., Pettersson H., Berg E., Brodin U., Trang L. Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5 year followup of a prospective double blind placebo controlled study. J Rheumatol. 1995 Dec;22(12):2208–2213. [PubMed] [Google Scholar]
- Emery P., Salmon M. Early rheumatoid arthritis: time to aim for remission? Ann Rheum Dis. 1995 Dec;54(12):944–947. doi: 10.1136/ard.54.12.944. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Feigenbaum S. L., Masi A. T., Kaplan S. B. Prognosis in rheumatoid arthritis. A longitudinal study of newly diagnosed younger adult patients. Am J Med. 1979 Mar;66(3):377–384. doi: 10.1016/0002-9343(79)91055-6. [DOI] [PubMed] [Google Scholar]
- Felson D. T., Anderson J. J., Boers M., Bombardier C., Chernoff M., Fried B., Furst D., Goldsmith C., Kieszak S., Lightfoot R. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials. Arthritis Rheum. 1993 Jun;36(6):729–740. doi: 10.1002/art.1780360601. [DOI] [PubMed] [Google Scholar]
- Fries J. F., Williams C. A., Bloch D. A. The relative toxicity of nonsteroidal antiinflammatory drugs. Arthritis Rheum. 1991 Nov;34(11):1353–1360. doi: 10.1002/art.1780341103. [DOI] [PubMed] [Google Scholar]
- Fries J. F., Williams C. A., Morfeld D., Singh G., Sibley J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996 Apr;39(4):616–622. doi: 10.1002/art.1780390412. [DOI] [PubMed] [Google Scholar]
- Fries J. F., Williams C. A., Ramey D., Bloch D. A. The relative toxicity of disease-modifying antirheumatic drugs. Arthritis Rheum. 1993 Mar;36(3):297–306. doi: 10.1002/art.1780360303. [DOI] [PubMed] [Google Scholar]
- Gough A. K., Lilley J., Eyre S., Holder R. L., Emery P. Generalised bone loss in patients with early rheumatoid arthritis. Lancet. 1994 Jul 2;344(8914):23–27. doi: 10.1016/s0140-6736(94)91049-9. [DOI] [PubMed] [Google Scholar]
- Gough A., Faint J., Salmon M., Hassell A., Wordsworth P., Pilling D., Birley A., Emery P. Genetic typing of patients with inflammatory arthritis at presentation can be used to predict outcome. Arthritis Rheum. 1994 Aug;37(8):1166–1170. doi: 10.1002/art.1780370809. [DOI] [PubMed] [Google Scholar]
- Green M., Marzo-Ortega H., McGonagle D., Wakefield R., Proudman S., Conaghan P., Gooi J., Emery P. Persistence of mild, early inflammatory arthritis: the importance of disease duration, rheumatoid factor, and the shared epitope. Arthritis Rheum. 1999 Oct;42(10):2184–2188. doi: 10.1002/1529-0131(199910)42:10<2184::AID-ANR20>3.0.CO;2-2. [DOI] [PubMed] [Google Scholar]
- Hannonen P., Möttönen T., Hakola M., Oka M. Sulfasalazine in early rheumatoid arthritis. A 48-week double-blind, prospective, placebo-controlled study. Arthritis Rheum. 1993 Nov;36(11):1501–1509. doi: 10.1002/art.1780361104. [DOI] [PubMed] [Google Scholar]
- Harrison B. J., Symmons D. P., Brennan P., Bankhead C. R., Barrett E. M., Scott D. G., Silman A. J. Inflammatory polyarthritis in the community is not a benign disease: predicting functional disability one year after presentation. J Rheumatol. 1996 Aug;23(8):1326–1331. [PubMed] [Google Scholar]
- Harrison B. J., Symmons D. P., Brennan P., Barrett E. M., Silman A. J. Natural remission in inflammatory polyarthritis: issues of definition and prediction. Br J Rheumatol. 1996 Nov;35(11):1096–1100. doi: 10.1093/rheumatology/35.11.1096. [DOI] [PubMed] [Google Scholar]
- Jansen L. M., van Schaardenburg D., van Der Horst-Bruinsma I. E., Bezemer P. D., Dijkmans B. A. Predictors of functional status in patients with early rheumatoid arthritis. Ann Rheum Dis. 2000 Mar;59(3):223–226. doi: 10.1136/ard.59.3.223. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kim J. M., Weisman M. H. When does rheumatoid arthritis begin and why do we need to know? Arthritis Rheum. 2000 Mar;43(3):473–484. doi: 10.1002/1529-0131(200003)43:3<473::AID-ANR1>3.0.CO;2-A. [DOI] [PubMed] [Google Scholar]
- Kraan M. C., Versendaal H., Jonker M., Bresnihan B., Post W. J., t Hart B. A., Breedveld F. C., Tak P. P. Asymptomatic synovitis precedes clinically manifest arthritis. Arthritis Rheum. 1998 Aug;41(8):1481–1488. doi: 10.1002/1529-0131(199808)41:8<1481::AID-ART19>3.0.CO;2-O. [DOI] [PubMed] [Google Scholar]
- Kroot E. J., van Leeuwen M. A., van Rijswijk M. H., Prevoo M. L., Van 't Hof M. A., van De Putte L. B., van Riel P. L. No increased mortality in patients with rheumatoid arthritis: up to 10 years of follow up from disease onset. Ann Rheum Dis. 2000 Dec;59(12):954–958. doi: 10.1136/ard.59.12.954. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lineker S., Badley E., Charles C., Hart L., Streiner D. Defining morning stiffness in rheumatoid arthritis. J Rheumatol. 1999 May;26(5):1052–1057. [PubMed] [Google Scholar]
- Machold K. P., Eberl G., Leeb B. F., Nell V., Windisch B., Smolen J. S. Early arthritis therapy: rationale and current approach. J Rheumatol Suppl. 1998 Jul;53:13–19. [PubMed] [Google Scholar]
- Masi A. T. Articular patterns in the early course of rheumatoid arthritis. Am J Med. 1983 Dec 30;75(6A):16–26. doi: 10.1016/0002-9343(83)90471-0. [DOI] [PubMed] [Google Scholar]
- McGonagle D., Conaghan P. G., O'Connor P., Gibbon W., Green M., Wakefield R., Ridgway J., Emery P. The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study. Arthritis Rheum. 1999 Aug;42(8):1706–1711. doi: 10.1002/1529-0131(199908)42:8<1706::AID-ANR20>3.0.CO;2-Z. [DOI] [PubMed] [Google Scholar]
- Munro R., Hampson R., McEntegart A., Thomson E. A., Madhok R., Capell H. Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study. Ann Rheum Dis. 1998 Feb;57(2):88–93. doi: 10.1136/ard.57.2.88. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Möttönen T. T. Prediction of erosiveness and rate of development of new erosions in early rheumatoid arthritis. Ann Rheum Dis. 1988 Aug;47(8):648–653. doi: 10.1136/ard.47.8.648. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Möttönen T., Paimela L., Leirisalo-Repo M., Kautiainen H., Ilonen J., Hannonen P. Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with "sawtooth" strategy. Ann Rheum Dis. 1998 Sep;57(9):533–539. doi: 10.1136/ard.57.9.533. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nissilä M., Isomäki H., Kaarela K., Kiviniemi P., Martio J., Sarna S. Prognosis of inflammatory joint diseases. A three-year follow-up study. Scand J Rheumatol. 1983;12(1):33–38. doi: 10.3109/03009748309102001. [DOI] [PubMed] [Google Scholar]
- Prevoo M. L., van Gestel A. M., van T Hof M. A., van Rijswijk M. H., van de Putte L. B., van Riel P. L. Remission in a prospective study of patients with rheumatoid arthritis. American Rheumatism Association preliminary remission criteria in relation to the disease activity score. Br J Rheumatol. 1996 Nov;35(11):1101–1105. doi: 10.1093/rheumatology/35.11.1101. [DOI] [PubMed] [Google Scholar]
- Scott D. L., Pugner K., Kaarela K., Doyle D. V., Woolf A., Holmes J., Hieke K. The links between joint damage and disability in rheumatoid arthritis. Rheumatology (Oxford) 2000 Feb;39(2):122–132. doi: 10.1093/rheumatology/39.2.122. [DOI] [PubMed] [Google Scholar]
- Shekelle P. G., Woolf S. H., Eccles M., Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999 Feb 27;318(7183):593–596. doi: 10.1136/bmj.318.7183.593. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Singh G., Rosen Ramey D. NSAID induced gastrointestinal complications: the ARAMIS perspective--1997. Arthritis, Rheumatism, and Aging Medical Information System. J Rheumatol Suppl. 1998 May;51:8–16. [PubMed] [Google Scholar]
- Solomon D. H., Bates D. W., Panush R. S., Katz J. N. Costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodologic standards. Ann Intern Med. 1997 Jul 1;127(1):52–60. doi: 10.7326/0003-4819-127-1-199707010-00009. [DOI] [PubMed] [Google Scholar]
- Speyer I., Hazes J. M., Breedveld F. C. Recruitment of patients with early rheumatoid arthritis -- the Netherlands experience. J Rheumatol Suppl. 1996 Mar;44:84–85. [PubMed] [Google Scholar]
- Symmons D. P., Jones M. A., Scott D. L., Prior P. Longterm mortality outcome in patients with rheumatoid arthritis: early presenters continue to do well. J Rheumatol. 1998 Jun;25(6):1072–1077. [PubMed] [Google Scholar]
- Tsakonas E., Fitzgerald A. A., Fitzcharles M. A., Cividino A., Thorne J. C., M'Seffar A., Joseph L., Bombardier C., Esdaile J. M. Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3 year followup on the hydroxychloroquine in early rheumatoid arthritis (HERA) study. J Rheumatol. 2000 Mar;27(3):623–629. [PubMed] [Google Scholar]
- Tunn E. J., Bacon P. A. Differentiating persistent from self-limiting symmetrical synovitis in an early arthritis clinic. Br J Rheumatol. 1993 Feb;32(2):97–103. doi: 10.1093/rheumatology/32.2.97. [DOI] [PubMed] [Google Scholar]
- Ward M. M., Leigh J. P., Fries J. F. Progression of functional disability in patients with rheumatoid arthritis. Associations with rheumatology subspecialty care. Arch Intern Med. 1993 Oct 11;153(19):2229–2237. [PubMed] [Google Scholar]
- Wolfe F., Hawley D. J., Cathey M. A. Clinical and health status measures over time: prognosis and outcome assessment in rheumatoid arthritis. J Rheumatol. 1991 Sep;18(9):1290–1297. [PubMed] [Google Scholar]
- Wolfe F. The prognosis of rheumatoid arthritis: assessment of disease activity and disease severity in the clinic. Am J Med. 1997 Dec 29;103(6A):12S–18S. doi: 10.1016/s0002-9343(97)90003-6. [DOI] [PubMed] [Google Scholar]
- Wolfe M. M., Lichtenstein D. R., Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999 Jun 17;340(24):1888–1899. doi: 10.1056/NEJM199906173402407. [DOI] [PubMed] [Google Scholar]
- Yelin E. H., Such C. L., Criswell L. A., Epstein W. V. Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition. Med Care. 1998 Apr;36(4):513–522. doi: 10.1097/00005650-199804000-00007. [DOI] [PubMed] [Google Scholar]
- Young A., Bielawska C., Corbett M., Roitt I. A prospective study of early onset rheumatoid arthritis over fifteen years: prognostic features and outcome. Clin Rheumatol. 1987 Sep;6 (Suppl 2):12–19. doi: 10.1007/BF02203380. [DOI] [PubMed] [Google Scholar]
- van Leeuwen M. A., Westra J., van Riel P. L., Limburg P. C., van Rijswijk M. H. IgM, IgA, and IgG rheumatoid factors in early rheumatoid arthritis predictive of radiological progression? Scand J Rheumatol. 1995;24(3):146–153. doi: 10.3109/03009749509099303. [DOI] [PubMed] [Google Scholar]
- van Leeuwen M. A., van der Heijde D. M., van Rijswijk M. H., Houtman P. M., van Riel P. L., van de Putte L. B., Limburg P. C. Interrelationship of outcome measures and process variables in early rheumatoid arthritis. A comparison of radiologic damage, physical disability, joint counts, and acute phase reactants. J Rheumatol. 1994 Mar;21(3):425–429. [PubMed] [Google Scholar]
- van Zeben D., Hazes J. M., Zwinderman A. H., Vandenbroucke J. P., Breedveld F. C. Factors predicting outcome of rheumatoid arthritis: results of a followup study. J Rheumatol. 1993 Aug;20(8):1288–1296. [PubMed] [Google Scholar]
- van der Heide A., Jacobs J. W., Bijlsma J. W., Heurkens A. H., van Booma-Frankfort C., van der Veen M. J., Haanen H. C., Hofman D. M., van Albada-Kuipers G. A., ter Borg E. J. The effectiveness of early treatment with "second-line" antirheumatic drugs. A randomized, controlled trial. Ann Intern Med. 1996 Apr 15;124(8):699–707. doi: 10.7326/0003-4819-124-8-199604150-00001. [DOI] [PubMed] [Google Scholar]
- van der Heide A., Jacobs J. W., Dinant H. J., Bijlsma J. W. The impact of endpoint measures in rheumatoid arthritis clinical trials. Semin Arthritis Rheum. 1992 Apr;21(5):287–294. doi: 10.1016/0049-0172(92)90022-6. [DOI] [PubMed] [Google Scholar]
- van der Heide A., Remme C. A., Hofman D. M., Jacobs J. W., Bijlsma J. W. Prediction of progression of radiologic damage in newly diagnosed rheumatoid arthritis. Arthritis Rheum. 1995 Oct;38(10):1466–1474. doi: 10.1002/art.1780381013. [DOI] [PubMed] [Google Scholar]
- van der Heijde D. M. Joint erosions and patients with early rheumatoid arthritis. Br J Rheumatol. 1995 Nov;34 (Suppl 2):74–78. [PubMed] [Google Scholar]
- van der Heijde D. M. Radiographic imaging: the 'gold standard' for assessment of disease progression in rheumatoid arthritis. Rheumatology (Oxford) 2000 Jun;39 (Suppl 1):9–16. doi: 10.1093/oxfordjournals.rheumatology.a031496. [DOI] [PubMed] [Google Scholar]
- van der Heijde D. M., van Riel P. L., van Leeuwen M. A., van 't Hof M. A., van Rijswijk M. H., van de Putte L. B. Prognostic factors for radiographic damage and physical disability in early rheumatoid arthritis. A prospective follow-up study of 147 patients. Br J Rheumatol. 1992 Aug;31(8):519–525. doi: 10.1093/rheumatology/31.8.519. [DOI] [PubMed] [Google Scholar]
- van der Horst-Bruinsma I. E., Speyer I., Visser H., Breedveld F. C., Hazes J. M. Diagnosis and course of early-onset arthritis: results of a special early arthritis clinic compared to routine patient care. Br J Rheumatol. 1998 Oct;37(10):1084–1088. doi: 10.1093/rheumatology/37.10.1084. [DOI] [PubMed] [Google Scholar]