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We can now affect the natural history of RA
Although the concept would sound heretical in some quarters, rheumatoid arthritis (RA) may now be a treatable disease. The aphorism of 25 years ago that “we don't treat RA, we manage the patient with the disease” may no longer be operative. Emery and colleagues in this issue of the Annals have made a recommendation (called a “clinical guide”) for how and when primary care physicians can identify patients with suspected RA and refer them to a rheumatology specialist.1 They state, unequivocally, that the initiation of disease modifying antirheumatic drugs (DMARDs) very early in the course of RA will improve patient outcome and increase long term quality of life. Their paper makes a compelling argument in favour of this recommendation; however, several issues dealt with in the article do raise questions that are in need of additional data and clarification.
THE APPROACH OF EMERY ET AL
Evaluation of published reports
The approach of Emery et al was to perform a literature database search and then to use an accepted classification scheme2 to evaluate published clinical evidence based on the potential for bias to influence the results, giving randomised clinical trials the highest marks and expert opinion the lowest. Well performed observational inception cohort studies appear to have received an intermediate value. The supporting evidence and the proposed clinical recommendation were later circulated among these six wise men for critical evaluation and consensus building. The net result of their efforts is not only a referral recommendation but also a practical clinical tool employed by primary care physicians to identify patients suspected of having RA during the early stages of the disease. The technique for evaluation of early RA, which has recently been validated,3 is based upon a composite compression test of the hand or “squeeze” test, illustrated in the article, …
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