Diagnosis, prognosis and classification of early arthritis: results of a systematic review informing the 2016 update of the EULAR recommendations for the management of early arthritis

Abstract

ObjectiveTo update the evidence pertaining to the diagnosis, prognosis and classification of patients with early arthritis (EA), and to inform the 2016 European League Against Rheumatism (EULAR) recommendations for the management of patients with EA.MethodsMEDLINE, EMBASE and Cochrane databases were searched up to October 2015. The first part of the systematic literature review (SLR) involved a search for studies investigating the recognition and referral of EA. The second part involved a search for studies to identify the place of laboratory and imaging tests in establishing a diagnosis and a prognosis in patients with EA.ResultsRegarding the issue of referral of patients with EA (1643 hits), 4 studies were included. These studies were in support of early referral for patients with EA. Regarding the issue of diagnosis and prognosis of patients with EA (11 435 hits), 88 studies were included, evaluating mainly the value of rheumatoid factor (RF) and anticitrullinated-peptide antibodies (ACPAs). Sensitivity of these antibodies for a RA diagnosis in patients with EA was moderate (40–80%). Specificity was higher, notably for ACPAs (frequently >80%). ACPAs also showed better prognostic performance than RF (negative predictive values around 80%). We confirmed that structural damage on baseline X-rays is predictive of further radiographic progression in patients with EA. Regarding other imaging modalities, data are sparse.ConclusionsThis SLR highlights the importance of early referral for patients with EA and confirms that RF and mainly ACPAs as well as a search for structural X-rays changes may help in the diagnosis and prognosis of patients with EA.

2016 update of the EULAR recommendations for the management of early arthritis

“…A delay in referral is one of the most important causes of late diagnosis and late start of effective treatment. Patients with early arthritis referred to a specialist within 3 months show better outcomes in terms of drug-free remission, radiographic damage and (less) need for orthopaedic surgery than those with late referral 15. This is also fully in line with standards of care developed for patients with RA and quality indicators as established by European Expert committees 21.…”

“…The search was completed by a hand search and by questioning experts for additional references. The SLR process is reported in detail in two separate articles 15 16…”

The 2016 Eular Guidelines for the Diagnosis and Treatment of Early Arthritis

“…Эта рекомендация подкрепляется данными многочисленных исследований, свидетельствующих о том, что задержка в направлении к ревматологу -одна из веду-щих причин поздней постановки диагноза, а следователь-но, назначения адекватной терапии [9,10,13,14].…”

“…Хотя в серии исследований продемонстрирована бо-лее высокая «чувствительность» УЗИ в отношении выявле-ния синовита мелких суставов кистей и коленного сустава [15], чем при клиническом осмотре, следует принимать во внимание низкую специфичность выявляемых при УЗИ изменений и отсутствие данных об их прогностическом значении в отношении риска развития РА [14]. Сходный вывод делается и в отношении магнитно-резонансной то-мографии (МРТ) [15,16].…”

“…В серии исследований показано, что «специфичность» од-номоментного обнаружения РФ и АЦЦП такая же, как только РФ или только АЦЦП [14,17,18 Важный аспект эффективного лечения раннего арт-рита связан с оптимизацией дозы МТ. Речь идет о быстрой эскалации дозы препарата (до 20-20 мг/нед), рациональ-ном применении подкожной формы МТ, которая должна рассматриваться при назначении высокой дозы препарата (≥15 мг/нед) или плохой переносимости таблетированной формы препарата [57].…”