1Are early arthritis clinics necessary?
Section snippets
What is an early arthritis clinic?
The first early rheumatoid arthritis (RA) clinical cohort was established in Bath, UK in 19571 with further cohorts established in Middlesex, UK2 and Memphis, Tennessee, USA3 in the 1960s. However, the concept of early arthritis clinics (EACs) only emerged in the late 1980s4 with growing evidence for the destructive and debilitating natural history of RA.5., 6. Conceptually, there were obvious clinical and academic benefits from this approach.
From the clinical perspective, if effective therapy
Who should be referred?
There are inherent difficulties in defining the patient population that is most appropriate for EAC assessment (Table 1). Of principal importance is the relationship with primary care and the awareness of the service provision offered. A letter detailing the aims and objectives of the service with the emphasis on improving patient outcomes is often useful and should be distributed to primary care colleagues. Reminding them of what services are available, developments in the field, and which
When should patients be referred?
In order for the maximum potential to be achieved from EACs, all patients with the potential to develop RA should be referred as soon as the condition is suspected in primary care. However, two critical areas of delay can be identified. The first is the time it takes the patient to recognize the symptoms of IA and seek appropriate medical advice. The second is the time it takes the primary care physician to make the diagnosis, as the earliest features of RA may be non-specific and inconclusive.
Disease assessment
As already mentioned, the EAC should offer rapid access for all patients with suspected RA (Table 3). Patient assessments should be comprehensive and provide a full diagnostic and prognostic evaluation. The more complete the initial review, the more likely it is that intervention or reassurance can be provided reliably. To allow objectivity, clinical assessments may be quantified, with the use of joint counts or composite scores such as the disease activity score (DAS).22., 23. Additional
What data should be collected?
The information collected from the EAC will vary between clinically-orientated and research-orientated services. It has, however, been proposed that a common core set of data should be collected in order for comparisons between series to be made.35 The proposed ‘standard protocol to evaluate rheumatoid arthritis’ comprises five pages of data collection that may be completed in 15–30 minutes.36 The data collected include clinical features such as the American College of Rheumatology (ACR)
Gains for the patient
The principal objective of the early arthritis movement was to improve patient assessment and outcome. A review of primary trial data from 14 randomized controlled trials of DMARD therapies in RA indicated disease duration as a significant determinant of response to therapy, with patients with short disease duration responding more favourably.39 Patients presenting with a disease duration of less than 1 year showed response in 53% of cases, whereas patients presenting with a disease duration of
Summary
The clinician is now better informed than ever regarding the assessment of early IA. Factors predicting persistence in early IA, in addition to new therapeutic options in previously unresearched areas, have been proposed. As well as assessing persistence where a diagnosis of RA is made, predicting severity is important for therapeutic decision making. Research tools, e.g. US and MRI, are being introduced into the clinic that may allow more specific case definition and severity assessment.Box 1
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Cited by (29)
Novel treatment strategies in rheumatoid arthritis
2017, The LancetCitation Excerpt :Only in later stages of the disease does the typical symmetric polyarthritis evolve.4 Thus, the immediate recognition of rheumatoid arthritis represents a challenge for physicians, and early referral, ideally to specialised early arthritis clinics, is critical to attaining more rapid assessment of patients with early-onset signs and symptoms of inflammatory arthritis.5 Early arthritis clinics screen patients with recent onset of joint pain clinically, using laboratory and imaging techniques.
Pain in arthritis
2009, European Journal of Pain SupplementsCitation Excerpt :On this basis we can understand the sense of the EACs, that offers the early assessment of patients with suspected EA. Ideally, these clinics should be able to evaluate the patients within 2 weeks of referral to the clinic, perform the processes of differential diagnosis and risk stratification of patients, with the identification of those at risk of persistent and erosive arthritis, and offer an early reassessment in order to evaluate the response to medical intervention on the basis of disease activity indexes fluctuation (Quinn, 2005). Regarding the treatment, in RA the early use of DMARDs is mandatory (Table 1); these drugs are an heterogeneous group of immunosuppressant that can block or slower the progression of arthritis.
Development of a scoring system for assessment of outcome of early undifferentiated inflammatory synovitis
2008, Joint Bone SpineCitation Excerpt :In contrast with the typical rheumatoid arthritis, inflammatory markers ESR and CRP were negative predictors for MRI findings, hence do not exclude abnormal MRI findings in patients with early arthritis. This data confirm the earlier reports showing that CRP and X-ray may be normal in 70 and 80% of cases respectively [24]. In another study, Green et al. [16] concluded that baseline CRP is not a predictor of persistent arthritis in very early inflammatory arthritis, which is in agreement with our data.
Development of a scoring system for assessment of outcome of early undifferentiated inflammatory synovitis
2008, Revue du Rhumatisme (Edition Francaise)Severity indices in rheumatoid arthritis: A systematic review
2019, Reumatologia Clinica