Background In patients with active rheumatoid arthritis (RA), early diagnosis and initiation of DMARD therapy can substantially improve the long-term outcome of disease, as well as overall quality of life. However, delay in referral to a rheumatologist for an accurate diagnosis of RA is a major obstacle to early treatment initiation. A clinical guideline that facilitates early referral of the patient with active RA, and thus the early initiation of DMARD therapy, is required so that treatment is initiated at the most appropriate time to positively impact on long-term morbidity and mortality.
Objectives To develop an ERR for early RA that would serve as a clinical guide for primary care physicians to identify patients with suspected RA during the early inflammatory stages of the disease.
Methods A literature search targeting early RA, early RA clinics (EACs), DMARD therapy for early RA, prognostic disease progression, early RA clinical trials and quality of life was performed. Published clinical evidence was reviewed and classified into categories I-IV (I = meta-analysis of/or randomised control trial; IV = expert opinion) and graded (A = category I; D = category IV) according to the methodology defined by Shekelle et al. (BMJ 1999;318: 593–6). Key points supported by relevant clinical evidence were developed and critically evaluated. Using an iterative process, participants’ views were incorporated into a final draft, resulting in a consensus statement.
Results Clinical evidence (Grade C) derived from EACs, prognostic factors for RA, and the consensus of the authors, resulted in the formation of the ERR, which states that rapid referral to a rheumatologist is necessary in the event of clinical suspicion of RA, which may be supported by the presence of any of the following: more than or equal to 3 swollen joints, metacarpophalangeal/metatarsophalangeal involvement and/or morning stiffness of more than or equal to 30 min. This recommendation is strongly supported by graded clinical evidence that structural damage occurs early in RA (Grade B&C) and that early DMARD therapy improves the long-term outcome of the disease (Grade A).
Conclusion The proposed ERR is a sensitive evidence-based tool that summarises essential diagnostic criteria derived from prospective clinical investigations and should be used to identify patients with early stage, active RA. The use of the EER should result in early referral to a rheumatologist for definitive diagnosis and early DMARD treatment, facilitating an improved long-term outcome in these patients.
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