The diagnosis of RA remains a clinical diagnosis based on the judgement by an experienced clinician. Nevertheless, the recently revised classification criteria for RA are widely used for diagnostic purposes. Several studies have investigated their performance “in real life” and have mostly confirmed that they have good metric properties and that they appear to support one of the explicit goals in their derivation, namely to allow for an earlier diagnosis in the patient with new-onset articular symptoms.
The increasing use of musculoskeletal ultrasound in rheumatological practice is beginning to make its impact felt on the diagnostic process as well. In a recent study based on the Bayesian principle of pre-test versus post-test probabilities we showed that the diagnostic certainty in early arthritis was significantly enhanced through the use of ultrasound (Rezaei et al, 2014). The use of fluorescent optical imaging (FOI, “rheumascan”) is still in its infancy but may have usefulness for diagnosing arthritis in the hands (Kisten et al, EULAR2014).
These novel imaging modalities, along with conventional and office-based MRI are also impacting on the assessment of RA during the course of the disease. As treatment options have increased, so has the importance of accurate assessment of the patient's disease state and response to treatment. The EULAR/ACR “Boolean” remission criteria have been studied and found to perform reasonably well, but it appears from several studies that the bar for the patient global assessment may have been set too stringently. Identifying clinically undetectable synovitis (silent synovitis) through imaging may also have implications for therapeutic decisions.
Biomarkers are being explored as a complement to the clinical assessment. In recent studies, we demonstrated that a multi-biomarker disease activity score accurately identified patients at risk for radiographic progression (Hambardzumyan, 2014), and more recent data suggest that it may help in choosing the optimal therapy in patients who fail methotrexate.
In summary, while the diagnosis and assessment of RA remain first and foremost clinical challenges, innovative imaging technologies and biomarkers are increasingly going to help the clinician make optimal decisions.
Disclosure of Interest R. van Vollenhoven Grant/research support from: AbbVie, BMS, GSK, Pfizer, Roche, UCB, Consultant for: AbbVie, Biotest, BMS, Crescendo, GSK, Janssen, Lilly, Merck, Pfizer, Roche, UCB, Vertex
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