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We read with interest the recent article by Hülsemann and Zeidler,1 in which the 1987 American College of Rheumatology (ACR) classification criteria for rheumatoid arthritis (RA) were evaluated for their ability to identify patients with a clinical diagnosis of RA among 217 patients referred to an early arthritis clinic. The authors concluded that the 1987 ACR criteria can be used to make a diagnosis of RA in this setting.
In this study, the “gold standard” against which the criteria were tested was an “expert diagnosis” made by one of the authors when the patient was first seen (within one year of symptom onset). However, the main difficulty facing the rheumatologist for patients with early disease is that patients who ultimately develop RA appear clinically similar to those who have self limiting disease or other forms of inflammatory arthritis. It is therefore too early to make an accurate diagnosis at this stage. More importantly, RA is a heterogeneous disease with a prognosis which varies from complete symptom remission to severe disability. Therefore simply categorising patients into those who do and do not have “RA” is not necessarily important when considering which patients require early treatment. Although the authors made a clinical diagnosis without using the classification criteria, it is likely that the diagnoses were informed by their knowledge of the individual components of the criteria. Therefore the high sensitivity (90%) they reported means that most of the patients with a clinical diagnosis of RA will have had seropositive, erosive, polyarticular disease with hand involvement. Whereas we have no problem in recognising these patients as having RA, it represents only one end of the spectrum. The proportion of patients with “undifferentiated arthritis” in this study is high (54%), though this has been reported in other series.2-3 It is likely that many of these patients have atypical RA which may still require treatment with disease modifying antirheumatic drugs. Further, in early disease, patients often do not satisfy some of the criteria (nodules, erosions) which are features of established RA. We therefore think it is misleading to imply that patients who do not satisfy the 1987 ACR criteria (a) do not have RA; and (b) do not require early, aggressive treatment.
We recently evaluated the performance of the 1987 ACR criteria in an unselected cohort of 486 patients newly presenting with inflammatory polyarthritis to the Norfolk Arthritis Register.4 We considered the practical question of whether the criteria could identify which patients would have a poor prognosis after three years as assessed by (a) persistent synovitis; (b) functional disability and (c) radiological erosions. Although we applied the criteria in a number of different ways, we found they had a low ability to discriminate between patients who developed persistent, disabling, and erosive disease and those who did not. For example, applying the criteria in the traditional “list” format, the positive predictive value for erosions was only 45% and the negative predictive value 67%. In practical terms, this means that 33% patients who did not satisfy the criteria developed erosions. However, given the fact that the 1987 ACR criteria were developed to distinguish between hospital attenders with established RA and patients with other musculoskeletal conditions, and were never intended to be used as diagnostic criteria, it is not surprising that they do not perform well in this setting.5
Finally, we wish to point out that the proportion of patients who satisfy the 1987 ACR criteria is highly dependent on how the criteria are applied. For example, in our study, the proportion of patients who satisfied the criteria at one year of follow up varied from 28% if applied “cross sectionally” (on the day of assessment) to 61% if applied “cumulatively” (each criterion satisfied if “ever” positive). Further difficulties are likely to be encountered using incomplete data ascertained from case note review. It is therefore more appropriate in a group with early synovitis to assess the criteria applied longitudinally at follow up, rather than simply at baseline.6 In the study by Hülsemann and Zeidler we were given no information about how or when the criteria were applied apart from that they were applied “retrospectively”.
We agree with Hülsemann and Zeidler that there is a need to “...differentiate RA as early as possible from the often benign and self-limited forms of undifferentiated arthritis, as there is a need for early treatment of RA”. However, we strongly disagree with the use of the 1987 ACR criteria for this purpose. Until we understand more about the pathogenesis of RA, clinicians will have to rely on clinical judgment and the presence of poor prognostic factors to make decisions about whether to treat aggressively patients presenting with early disease.
We agree with Harrison et al that the main difficulty for a rheumatologist in early arthritis is to distinguish progressive rheumatoid arthritis from self limiting disease and other forms of arthritis that do not show a progressive course. Nevertheless, there is also a need in clinical practice for the primary care doctors and the patient to perform, as early as possible, a nosological differentiation between RA and the whole spectrum of other arthritides and spondarthritides.
We have described the incidence of undifferentiated arthritis to be as high as 54%.1-1 When patients were seen in this early synovitis outpatient clinic between 1984 and 1986, the 1958 American Rheumatism Association (ARA) criteria had not been revised. Expert diagnoses were made with knowledge of the 1958 ARA criteria for the diagnosis of RA1-2 but were not the basis of diagnoses. Trained as clinicians, rheumatologists never used the ACR criteria for diagnosis making. Only in retrospect, were the 1987 revised ACR criteria applied. These are criteria for classification of RA.1-3 The intention was to investigate the performance of these criteria in early synovitis with a high proportion of undifferentiated and reactive arthritides. Since the performance was good with a high sensitivity (90%) and a high specificity (90%), we suggested, that these criteria could be used not only as classification criteria but also as criteria for diagnosis of RA.
Criteria should be applied longitudinally at follow up, rather than simply at baseline. We applied criteria cross sectionally on the day of their first visit. We can not present follow up data on the whole group, but of a subgroup of 28 patients with undifferentiated arthritis.1-1 Only two of these patients developed rheumatoid factor negative RA, 15 patients showed complete remission, two showed partial remission, eight had unchanged or progressive unclassified arthritis, and one patient had developed ankylosing spondylitis.
In accordance with our experience, van der Horst-Bruinsmaet al have shown, in a special early arthritis clinic, that early diagnosis of RA is possible and reliable.1-4 Compared with routine patient care, of 74 patients with definite RA according to the 1987 ACR criteria, diagnosed at two weeks after the first visit, 66 still had definite RA after one year, and in only four patients was the diagnosis changed to systemic lupus erythematosus (one), unclassified arthritis (one), gout (one), and probable RA (one). Two patients had died and two were lost to follow up. This shows, that the validity is high for the 1987 ACR criteria for differentiating between RA and non-RA arthritides in an early synovitis clinic.
We do not imply that patients who do not fulfil the 1987 ARA criteria do not have RA. If they do not fulfil the criteria at this early stage, we classify them as having undifferentiated arthritis. This is a working diagnosis, which can be changed to a definite diagnosis during follow up, but is only rarely necessary, as our experience and that of others show.
The 1987 ACR criteria are not valid for prognostic purposes as Harrisonet al stated.1-5 Other prognostic factors exist and can easily be applied to patients with RA.1-6 But the ACR criteria for RA in our view are an important means of helping family doctors and general practitioners not trained in rheumatology to make a diagnosis of RA and to differentiate between RA and other forms of arthritides as soon as possible in the course of the disease. Thus by early referral to a rheumatologist an adequate treatment can be started as soon as possible. Even rheumatologists, who are familiar with the criteria used in all controlled trials to establish present treatment guidelines, are, in our view, well supported in every day practice by applying the 1987 ACR criteria to differentiate RA from other forms of arthritis, enabling early diagnosis and treatment decisions.
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