Recommendation (with level of evidence and grade of recommendation) | Agreement mean (SD) |
---|---|
1. All possible causes of arthritis (idiopathic, autoimmune, degenerative, infectious, malignancy, traumatic, metabolic) should be considered in the differential diagnosis. Complete history and thorough physical examination will determine the ranking order of possible differential diagnoses [5, D]. Investigations should be based on the differential diagnosis of the patient [5, D] | 9.0 (1.7) |
2. To establish a specific diagnosis and prognosis following presentation of UPIA, a careful systematic history and physical examination should be performed, with particular attention to age, gender [1a, A], geographical area [5, D], functional status [1a, A], duration of symptoms/early morning stiffness, number plus pattern of tender/swollen joints [1a, A], axial/entheseal involvement and extra-articular/systemic features [5, D] | 8.8 (1.3) |
3. ESR and CRP should be performed at baseline in the investigation for diagnosis [2b, B] and prognosis [2b, B] of UPIA and repeated when clinically relevant [5, D] | 9.1 (1.4) |
4. Testing of RF and/or ACPA should be performed in the evaluation of patients with UPIA, as these factors are predictive of RA diagnosis and prognosis; negative tests do not exclude progression to RA [1a, A]. If a connective tissue disease/systemic inflammatory disorder is suspected, additional autoantibody tests should be considered [5, D] | 9.1 (1.2) |
5. X-rays of affected joints should be performed at baseline [5, D]. X-rays of hands, wrists and feet should be considered in the evaluation of UPIA as the presence of erosions is predictive for the development of RA and persistence of disease [1a, A]. These should be repeated within 1 year [5, D] | 7.4 (2.6) |
6. There is insufficient evidence to recommend the routine use of MRI and US for diagnosis or prognosis in UPIA [5, D]; in UPIA and suspicion of RA, MRI of hands and wrists could be considered for diagnosis [2b, B] | 8.2 (2.0) |
7. There is no genetic test that can be routinely recommended [3b, D], however HLA-B27 testing may be helpful in specific clinical settings [5, D] | 8.8 (1.5) |
8. Routine synovial biopsy is not recommended but can give information for differential diagnosis, especially in patients with persistent monoarthritis [2b, B] | 8.8 (1.8) |
9. Predictors of persistent inflammatory arthritis should be documented and include disease duration of ≥6 weeks [1b, A], morning stiffness >30 min [4, C], functional impairment [4, C], involvement of small joints [4, C] and/or knee [4, C], involvement of ≥3 joints [1b, B], ACPA [4, C] and/or RF positivity [4, C] and presence of radiographic erosion [1b, B] | 8.6 (1.7) |
10. Disease activity should be monitored [5, D], however no specific tool can be recommended [3b, C] | 9.0 (1.7) |
Values in square brackets indicate [level of evidence, grade of recommendation] according to the Oxford Centre for Evidence-based Medicine levels of evidence.
Agreement was voted on a scale from 1 to 10 (fully disagree to fully agree) by the 94 rheumatologists attending the 3E Multi-National Closing Meeting. These attendees were members of the 17 scientific committees involved in the 3E Initiative of 2008–2009.
ACPA, anti-citrullinated protein/peptide antibodies; CRP, C reactive protein; ESR, erythrocyte sedimentation rate; RA, rheumatoid arthritis; RF, rheumatoid factor; UPIA, undifferentiated peripheral inflammatory arthritis; US, ultrasound.