1. Consultant Rheumatologist
Rheumatoid arthritis: the importance of early diagnosis and treatment November 2011
Helen Linklater
Consultant Rheumatologist
Epsom and St Helier

2. The race to diagnosis... £1.8 billion a year!
Common: 1% of adults worldwide
Progressive:
joint pain
joint damage
increased mortality
Estimated cost of sick leave/work-related disability for people with RA:
£1.8 billion a year!
DISABILITY

3. A new approach...

6. What is early RA?
“Very early” = three months after disease onset (Hyrich, 2008)
This may be a window of opportunity
“Early” =  12 months into disease (Hyrich, 2008)
Prompt introduction of DMARDs can lead to benefits up to 5 years after the drugs are introduced when compared with a delayed start (Raza, 2010)

7. Spotting a winner...
Undifferentiated inflammatory arthritis (anti-CCP positive) treated with 12/12 methotrexate - outcome at 18 months
Early therapeutic intervention improves clinical outcomes
(van Dongen, 2007)

8. Diagnosing early RA - before damage occurs
Anti-CCP
Ultrasound
MRI imaging +/- gadolinium

9. Anti-CCP - anti-cyclic citrullinated peptide (CCP) Diagnosis ACPA
Anti-citrullinated peptide antibody (ACPA)
- anti-cyclic citrullinated peptide (CCP)
Diagnosis
 50% patients with RA have anti-CCP or IgM-RF several years before symptom onset (Nielen, 2004)
Strongly associated with genetic phenotypes associated with RA, and with smoking
ACPA
Prognosis
Poorer response to therapy
Predicts erosions
(Aggarwal, 2009)
> 95% positive predictive value in early inflammatory arthritis

10. Ultrasound assessment
MCP joint
Synovial hypertrophy
Synovial fluid
Synovial thickening
Effusion
PP head
MC head
MCP joint
Erosion
Power Doppler
Doppler signal
Erosion
But operator dependent, non-standardised, variability...

11. ACR/EULAR criteria 2010

14. Obstacles to treating early RA...
Services for people with rheumatoid arthritis 15 July 2009
% people with RA delay seeking medical help from GP for  3 months following symptom onset
- 20% delay for  1 year
- Average length of time (symptom onset - Rx) 9 months
Subject of much research!

15. Combination therapy in early RA
 2 DMARDs
+ steroid
DMARD +
Infliximab
Difficult to have complex treatment discussion at diagnosis
Time limitations
Lack of CNS support
% without
radiological
progression
“Despite …evidence in
favour of intensive treatment strategies based on combinations of DMARDs with glucocorticoids... they are not often used in daily practice”
BeSt Study (2005)
(Verschueren, 2011)

16. Summary New criteria explicitly designed to find early disease
ACPA very specific
USS/MRI imaging aids diagnosis
Facilitates disease stratification and early treatment

17. Does this alter your practice?
Persistent joint swelling in  1 joint, or involvement of MCP or MTP joints = consider urgent referral (ideally within 6 wks of symptom onset)
RhF and radiographs will probably be normal (NICE, 2009)

19. References
1. Hyrich, K Patients with suspected rheumatoid arthritis should be referred early to rheumatology BMJ : 215
2. Raza, K The Michael Mason prize: early rheumatoid
arthritis—the window narrows Rheumatology 2010;49:406–410
3. Van Dongen H et al. Efficacy of Methotrexate Treatment in Patients With Probable Rheumatoid Arthritis Arthritis and Rheumatism 56, No. 5, May 2007, pp 1424–1432
4. Nielen M et al (2004) Specific Autoantibodies Precede the Symptoms of Rheumatoid Arthritis Arthritis and Rheumatism 50, (2) pp 380–386
5. Aggarwal, R et al (2009) Anti–Citrullinated Peptide Antibody Assays and Their Role in the Diagnosis of Rheumatoid Arthritis Arthritis & Rheumatism (Arthritis Care & Research) 61 (11) pp 1472–1483
5. ACR/EULAR Classification criteria for RA 2010
6. Verschueren P, Westhovens R Optimal care for early RA patients: the challenge of translating scientific data into clinical practice Rheumatology 2011;50:
7. NICE guidance CG79 (Feb 2009) Rheumatoid arthritis: the management of rheumatoid arthritis in adults

20. Any Questions?