Background Early diagnosis and prognostic stratification are central issues in the management of early arthritis and rheumatoid arthritis (RA), with several baseline features affecting relevant outcomes 1,2.
Objectives To evaluate the influence of referral criteria and pattern of joint involvement on the achievement of DAS28 remission at 12 months in patients with early arthritis.
Methods Consecutive patients attending an early arthritis clinic between 2005 and 2013 were enrolled. Referral criteria included joint stiffness>30 minutes, joint swelling and positive squeezing test (ST) at metacarpophalangeal or metatarsophalangeal joints. Baseline demographic features, disease activity, symptom duration and pattern of symptom onset (inflammatory pain, joint stiffness, monoarthritis, oligoarthiritis or polyarthritis) were recorded. Patients classified as RA were treated with methotrexate, while patients with undifferentiated arthritis with hydroxichloroquine. Low-dose oral prednisone could be given. Patients were subsequently treated according to a DAS28 driven step-up protocol in order to achieve low disease activity3, they were seen every 2 months in the first six months and every 3 afterwards, DAS28 was recorded at each evaluation. The outcome of interest was clinical remission (DAS28<2.6) occurring within the first 12 months of follow-up. Analyses on remission were done using a Cox proportional hazard regression analysis, results presented as crude hazard ratios (HR) and 95% confidence intervals (CI) and adjusted for age, gender, symptom duration at presentation, rheumatoid factor and/or ACPA positivity, baseline DAS28, use of steroids and MTX dose.
Results A total of 772 patients were included. Mean age (SD) was 57.78 (14.94) years, 73.06% were female, 36.9% had positive rheumatoid factor, 68.6% fulfilled the 2010 criteria for RA, mean DAS28 was 4.60 (1.23) median (IQR) symptom duration was 15.1 (8.8-28.8) weeks (IQR). 72.7% were referred for positive ST, 66.7% for joint effusion, 56.5% for stiffness. 56.7% of patients presented with polyarthritis, 17.3% with inflammatory pain, 15.3% with oligoarthritis, 4.8% monoarthritis, 3.8% stiffness, 1.8% other presentation. The influence of referral criteria and clinical onset on remission achievement at 12 months is collected in Table 1.
Conclusions Patients referred for ST positivity are less likely to achieve remission at 12 months than patients referred for swelling or stiffness. Similarly patients with oligoarticular or polyarticular onset achieve remission less frequently.
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Machold KP et al, Rheumatology 2007;46:342–349.
Sakellariou G. et al, Ann Rheum Dis 2013;72:245-9.
Disclosure of Interest None declared
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