HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi
Part 2 of 8 in Diagnosis and Management of Rheumatoid Arthritis
Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
September 1, 2024
The 1987 American College of Rheumatology criteria for rheumatoid arthritis used seven features, of which four had to be present: early morning stiffness, arthritis in more than three joint areas, arthritis of the hand joints, symmetric arthritis, rheumatoid nodules, a positive rheumatoid factor, and radiographic changes.
Why the 1987 criteria missed early disease
The problem was that several of these features, radiographic changes and rheumatoid nodules especially, only appear at late stages of the disease, and symmetric arthritis or involvement of three or more joint areas may not be present early either. The anti-CCP antibody, now a key diagnostic marker, didn't exist yet in 1987 and so was never part of the criteria. As a result, the 1987 criteria had a sensitivity of only around 50% in early rheumatoid arthritis.
The 2010 ACR/EULAR criteria
To catch the disease earlier, the American College of Rheumatology and EULAR (the European League Against Rheumatism) proposed new criteria in 2010. Two entry requirements apply: at least one swollen joint, and that synovitis isn't better explained by another disease. From there, four domains are scored: the number and type of joints involved, rheumatoid factor and anti-CCP antibody status, symptom duration (less or more than six weeks), and acute phase reactants (ESR and CRP). A patient scoring six or more points out of a possible ten is classified as having definite rheumatoid arthritis. This criteria has a sensitivity of around 80%, though its specificity is lower, at around 70%.
This article is based on a Jivo Masterclass session conducted by Dr. Sajal Ajmani, HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sajal Ajmani taught doctors across Africa on September 1, 2024.
FROM THE LIVE Q&A
Dr. Bafomba
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?
Dr. Sajal Ajmani
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
Frequently Asked Questions
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?▼
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?▼
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
What is the recommended medical treatment for palindromic rheumatism?▼
Hydroxychloroquine.
What is the definition of sustained remission?▼
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?▼
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
Why were the 1987 RA criteria replaced?▼
Several of the 1987 criteria, like radiographic changes and rheumatoid nodules, only appear at late disease stages, giving the criteria only around 50% sensitivity in early RA, and anti-CCP antibody testing didn't exist yet in 1987.
What score is needed for a 2010 ACR/EULAR RA diagnosis?▼
Six or more points across four domains: joint involvement, serology (RF/anti-CCP), symptom duration, and acute phase reactants (ESR/CRP), after confirming at least one swollen joint not explained by another disease.
In This Series: Diagnosis and Management of Rheumatoid Arthritis
- 1.Diagnosis and Management of Rheumatoid Arthritis
- 2.Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
- 3.Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
- 4.Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
- 5.Monitoring Disease Activity: DAS28, SDAI, CDAI and the ACR Response Criteria
- 6.Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
- 7.Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
- 8.Extra-Articular Rheumatoid Arthritis: Lung, Eye, Heart, Kidney and Skin Involvement