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Ann Rheum Dis. Apr 2002; 61(4): 290–297.
PMCID: PMC1754044

Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide

Abstract

Objective: To develop a referral recommendation that may serve as a clinical guide for primary care doctors, enabling them to identify patients with suspected RA during the early inflammatory stages.

Methods: Key points of the referral criteria were formed based on a thorough literature review targeting early RA, early arthritis clinics, DMARD treatment for early RA, prognostic factors of disease progression, early RA clinical trials, and quality of life. Evidence was graded using the methods defined by Shekelle et al. A draft version of the criterion was circulated among the authors for critical evaluation. A consensus integrated these comments.

Results: Clinical evidence strongly supports the observations that structural damage occurs early in active RA and that early DMARD treatment improves the long term outcome of the disease. The observations indicate that rapid referral to a rheumatologist is advised when RA is suspected. This may be supported by the presence of any of the following: ≥3 swollen joints, metatarsophalangeal/metacarpophalangeal involvement, and morning stiffness of ≥30 minutes.

Conclusion: The proposed early referral recommendation is a viable tool for primary care doctors to identify potential patients with active RA early in the disease. Early referral to a rheumatologist for definitive diagnosis and early DMARD treatment should improve the long term outcome of RA.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Callahan LF. The burden of rheumatoid arthritis: facts and figures. J Rheumatol Suppl. 1998 Jul;53:8–12. [PubMed]
  • Buckley CD. Science, medicine, and the future. Treatment of rheumatoid arthritis. BMJ. 1997 Jul 26;315(7102):236–238. [PMC free article] [PubMed]
  • Criswell LA, Such CL, Yelin EH. Differences in the use of second-line agents and prednisone for treatment of rheumatoid arthritis by rheumatologists and non-rheumatologists. J Rheumatol. 1997 Dec;24(12):2283–2290. [PubMed]
  • Yelin EH, Such CL, Criswell LA, Epstein WV. Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition. Med Care. 1998 Apr;36(4):513–522. [PubMed]
  • Ward MM, Leigh JP, Fries JF. Progression of functional disability in patients with rheumatoid arthritis. Associations with rheumatology subspecialty care. Arch Intern Med. 1993 Oct 11;153(19):2229–2237. [PubMed]
  • Solomon DH, Bates DW, Panush RS, Katz JN. Costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodologic standards. Ann Intern Med. 1997 Jul 1;127(1):52–60. [PubMed]
  • Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999 Feb 27;318(7183):593–596. [PMC free article] [PubMed]
  • van der Heijde DM. Radiographic imaging: the 'gold standard' for assessment of disease progression in rheumatoid arthritis. Rheumatology (Oxford) 2000 Jun;39 (Suppl 1):9–16. [PubMed]
  • van der Heijde DM. Joint erosions and patients with early rheumatoid arthritis. Br J Rheumatol. 1995 Nov;34 (Suppl 2):74–78. [PubMed]
  • Scott DL, Pugner K, Kaarela K, Doyle DV, Woolf A, Holmes J, Hieke K. The links between joint damage and disability in rheumatoid arthritis. Rheumatology (Oxford) 2000 Feb;39(2):122–132. [PubMed]
  • Drossaers-Bakker KW, de Buck M, van Zeben D, Zwinderman AH, Breedveld FC, Hazes JM. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arthritis Rheum. 1999 Sep;42(9):1854–1860. [PubMed]
  • Gough AK, Lilley J, Eyre S, Holder RL, Emery P. Generalised bone loss in patients with early rheumatoid arthritis. Lancet. 1994 Jul 2;344(8914):23–27. [PubMed]
  • Devlin J, Lilley J, Gough A, Huissoon A, Holder R, Reece R, Perkins P, Emery P. Clinical associations of dual-energy X-ray absorptiometry measurement of hand bone mass in rheumatoid arthritis. Br J Rheumatol. 1996 Dec;35(12):1256–1262. [PubMed]
  • Deodhar AA, Brabyn J, Jones PW, Davis MJ, Woolf AD. Longitudinal study of hand bone densitometry in rheumatoid arthritis. Arthritis Rheum. 1995 Sep;38(9):1204–1210. [PubMed]
  • McGonagle D, Conaghan PG, O'Connor P, Gibbon W, Green M, Wakefield R, Ridgway J, Emery P. The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study. Arthritis Rheum. 1999 Aug;42(8):1706–1711. [PubMed]
  • Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ, Raber H, Hamm B, Burmester GR, Bollow M. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum. 1999 Jun;42(6):1232–1245. [PubMed]
  • Kraan MC, Versendaal H, Jonker M, Bresnihan B, Post WJ, t Hart BA, Breedveld FC, Tak PP. Asymptomatic synovitis precedes clinically manifest arthritis. Arthritis Rheum. 1998 Aug;41(8):1481–1488. [PubMed]
  • Kim JM, Weisman MH. When does rheumatoid arthritis begin and why do we need to know? Arthritis Rheum. 2000 Mar;43(3):473–484. [PubMed]
  • Anderson JJ, Wells G, Verhoeven AC, Felson DT. Factors predicting response to treatment in rheumatoid arthritis: the importance of disease duration. Arthritis Rheum. 2000 Jan;43(1):22–29. [PubMed]
  • Kroot EJ, van Leeuwen MA, van Rijswijk MH, Prevoo ML, Van 't Hof MA, van De Putte LB, van Riel PL. No increased mortality in patients with rheumatoid arthritis: up to 10 years of follow up from disease onset. Ann Rheum Dis. 2000 Dec;59(12):954–958. [PMC free article] [PubMed]
  • Symmons DP, Jones MA, Scott DL, Prior P. Longterm mortality outcome in patients with rheumatoid arthritis: early presenters continue to do well. J Rheumatol. 1998 Jun;25(6):1072–1077. [PubMed]
  • Abu-Shakra M, Toker R, Flusser D, Flusser G, Friger M, Sukenik S, Buskila D. Clinical and radiographic outcomes of rheumatoid arthritis patients not treated with disease-modifying drugs. Arthritis Rheum. 1998 Jul;41(7):1190–1195. [PubMed]
  • Fries JF, Williams CA, Morfeld D, Singh G, Sibley J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996 Apr;39(4):616–622. [PubMed]
  • Edworthy SM. Morning stiffness: sharpening an old saw? J Rheumatol. 1999 May;26(5):1015–1017. [PubMed]
  • Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999 Jun 17;340(24):1888–1899. [PubMed]
  • Singh G, Rosen Ramey D. NSAID induced gastrointestinal complications: the ARAMIS perspective--1997. Arthritis, Rheumatism, and Aging Medical Information System. J Rheumatol Suppl. 1998 May;51:8–16. [PubMed]
  • Fries JF, Williams CA, Bloch DA. The relative toxicity of nonsteroidal antiinflammatory drugs. Arthritis Rheum. 1991 Nov;34(11):1353–1360. [PubMed]
  • Fries JF, Williams CA, Ramey D, Bloch DA. The relative toxicity of disease-modifying antirheumatic drugs. Arthritis Rheum. 1993 Mar;36(3):297–306. [PubMed]
  • Emery P, Salmon M. Early rheumatoid arthritis: time to aim for remission? Ann Rheum Dis. 1995 Dec;54(12):944–947. [PMC free article] [PubMed]
  • Machold KP, Eberl G, Leeb BF, Nell V, Windisch B, Smolen JS. Early arthritis therapy: rationale and current approach. J Rheumatol Suppl. 1998 Jul;53:13–19. [PubMed]
  • Nissilä M, Isomäki H, Kaarela K, Kiviniemi P, Martio J, Sarna S. Prognosis of inflammatory joint diseases. A three-year follow-up study. Scand J Rheumatol. 1983;12(1):33–38. [PubMed]
  • Speyer I, Hazes JM, Breedveld FC. Recruitment of patients with early rheumatoid arthritis -- the Netherlands experience. J Rheumatol Suppl. 1996 Mar;44:84–85. [PubMed]
  • Green M, Marzo-Ortega H, McGonagle D, Wakefield R, Proudman S, Conaghan P, Gooi J, Emery P. Persistence of mild, early inflammatory arthritis: the importance of disease duration, rheumatoid factor, and the shared epitope. Arthritis Rheum. 1999 Oct;42(10):2184–2188. [PubMed]
  • Chan KW, Felson DT, Yood RA, Walker AM. The lag time between onset of symptoms and diagnosis of rheumatoid arthritis. Arthritis Rheum. 1994 Jun;37(6):814–820. [PubMed]
  • van der Horst-Bruinsma IE, Speyer I, Visser H, Breedveld FC, Hazes JM. Diagnosis and course of early-onset arthritis: results of a special early arthritis clinic compared to routine patient care. Br J Rheumatol. 1998 Oct;37(10):1084–1088. [PubMed]
  • Wolfe F, Hawley DJ, Cathey MA. Clinical and health status measures over time: prognosis and outcome assessment in rheumatoid arthritis. J Rheumatol. 1991 Sep;18(9):1290–1297. [PubMed]
  • Möttönen TT. Prediction of erosiveness and rate of development of new erosions in early rheumatoid arthritis. Ann Rheum Dis. 1988 Aug;47(8):648–653. [PMC free article] [PubMed]
  • Jansen LM, van Schaardenburg D, van Der Horst-Bruinsma IE, Bezemer PD, Dijkmans BA. Predictors of functional status in patients with early rheumatoid arthritis. Ann Rheum Dis. 2000 Mar;59(3):223–226. [PMC free article] [PubMed]
  • Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315–324. [PubMed]
  • Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M, Fried B, Furst D, Goldsmith C, Kieszak S, Lightfoot R, et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials. Arthritis Rheum. 1993 Jun;36(6):729–740. [PubMed]
  • van der Heide A, Jacobs JW, Dinant HJ, Bijlsma JW. The impact of endpoint measures in rheumatoid arthritis clinical trials. Semin Arthritis Rheum. 1992 Apr;21(5):287–294. [PubMed]
  • Anderson JJ, Chernoff MC. Sensitivity to change of rheumatoid arthritis clinical trial outcome measures. J Rheumatol. 1993 Mar;20(3):535–537. [PubMed]
  • Lineker S, Badley E, Charles C, Hart L, Streiner D. Defining morning stiffness in rheumatoid arthritis. J Rheumatol. 1999 May;26(5):1052–1057. [PubMed]
  • Brennan P, Harrison B, Barrett E, Chakravarty K, Scott D, Silman A, Symmons D. A simple algorithm to predict the development of radiological erosions in patients with early rheumatoid arthritis: prospective cohort study. BMJ. 1996 Aug 24;313(7055):471–476. [PMC free article] [PubMed]
  • Combe B, Dougados M, Goupille P, Cantagrel A, Eliaou JF, Sibilia J, Meyer O, Sany J, Daurès JP, Dubois A. Prognostic factors for radiographic damage in early rheumatoid arthritis: a multiparameter prospective study. Arthritis Rheum. 2001 Aug;44(8):1736–1743. [PubMed]
  • Feigenbaum SL, Masi AT, Kaplan SB. Prognosis in rheumatoid arthritis. A longitudinal study of newly diagnosed younger adult patients. Am J Med. 1979 Mar;66(3):377–384. [PubMed]
  • Gough A, Faint J, Salmon M, Hassell A, Wordsworth P, Pilling D, Birley A, Emery P. Genetic typing of patients with inflammatory arthritis at presentation can be used to predict outcome. Arthritis Rheum. 1994 Aug;37(8):1166–1170. [PubMed]
  • Möttönen T, Paimela L, Leirisalo-Repo M, Kautiainen H, Ilonen J, Hannonen P. Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with "sawtooth" strategy. Ann Rheum Dis. 1998 Sep;57(9):533–539. [PMC free article] [PubMed]
  • van der Heide A, Remme CA, Hofman DM, Jacobs JW, Bijlsma JW. Prediction of progression of radiologic damage in newly diagnosed rheumatoid arthritis. Arthritis Rheum. 1995 Oct;38(10):1466–1474. [PubMed]
  • van der Heijde DM, van Riel PL, van Leeuwen MA, van 't Hof MA, van Rijswijk MH, van de Putte LB. Prognostic factors for radiographic damage and physical disability in early rheumatoid arthritis. A prospective follow-up study of 147 patients. Br J Rheumatol. 1992 Aug;31(8):519–525. [PubMed]
  • van Leeuwen MA, Westra J, van Riel PL, Limburg PC, van Rijswijk MH. IgM, IgA, and IgG rheumatoid factors in early rheumatoid arthritis predictive of radiological progression? Scand J Rheumatol. 1995;24(3):146–153. [PubMed]
  • van Zeben D, Hazes JM, Zwinderman AH, Vandenbroucke JP, Breedveld FC. Factors predicting outcome of rheumatoid arthritis: results of a followup study. J Rheumatol. 1993 Aug;20(8):1288–1296. [PubMed]
  • Eberhardt K, Fex E. Clinical course and remission rate in patients with early rheumatoid arthritis: relationship to outcome after 5 years. Br J Rheumatol. 1998 Dec;37(12):1324–1329. [PubMed]
  • Harrison BJ, Symmons DP, Brennan P, Bankhead CR, Barrett EM, Scott DG, Silman AJ. Inflammatory polyarthritis in the community is not a benign disease: predicting functional disability one year after presentation. J Rheumatol. 1996 Aug;23(8):1326–1331. [PubMed]
  • van Leeuwen MA, van der Heijde DM, van Rijswijk MH, Houtman PM, van Riel PL, van de Putte LB, Limburg PC. Interrelationship of outcome measures and process variables in early rheumatoid arthritis. A comparison of radiologic damage, physical disability, joint counts, and acute phase reactants. J Rheumatol. 1994 Mar;21(3):425–429. [PubMed]
  • Young A, Bielawska C, Corbett M, Roitt I. A prospective study of early onset rheumatoid arthritis over fifteen years: prognostic features and outcome. Clin Rheumatol. 1987 Sep;6 (Suppl 2):12–19. [PubMed]
  • Harrison BJ, Symmons DP, Brennan P, Barrett EM, Silman AJ. Natural remission in inflammatory polyarthritis: issues of definition and prediction. Br J Rheumatol. 1996 Nov;35(11):1096–1100. [PubMed]
  • Masi AT. Articular patterns in the early course of rheumatoid arthritis. Am J Med. 1983 Dec 30;75(6A):16–26. [PubMed]
  • Prevoo ML, van Gestel AM, van T Hof MA, van Rijswijk MH, van de Putte LB, van Riel PL. Remission in a prospective study of patients with rheumatoid arthritis. American Rheumatism Association preliminary remission criteria in relation to the disease activity score. Br J Rheumatol. 1996 Nov;35(11):1101–1105. [PubMed]
  • Tunn EJ, Bacon PA. Differentiating persistent from self-limiting symmetrical synovitis in an early arthritis clinic. Br J Rheumatol. 1993 Feb;32(2):97–103. [PubMed]
  • Wolfe F. The prognosis of rheumatoid arthritis: assessment of disease activity and disease severity in the clinic. Am J Med. 1997 Dec 29;103(6A):12S–18S. [PubMed]
  • Borg G, Allander E, Lund B, Berg E, Brodin U, Pettersson H, Trang L. Auranofin improves outcome in early rheumatoid arthritis. Results from a 2-year, double blind placebo controlled study. J Rheumatol. 1988 Dec;15(12):1747–1754. [PubMed]
  • Davis MJ, Dawes PT, Fowler PD, Clarke S, Fisher J, Shadforth MF. Should disease-modifying agents be used in mild rheumatoid arthritis? Br J Rheumatol. 1991 Dec;30(6):451–454. [PubMed]
  • Hannonen P, Möttönen T, Hakola M, Oka M. Sulfasalazine in early rheumatoid arthritis. A 48-week double-blind, prospective, placebo-controlled study. Arthritis Rheum. 1993 Nov;36(11):1501–1509. [PubMed]
  • Buckland-Wright JC, Clarke GS, Chikanza IC, Grahame R. Quantitative microfocal radiography detects changes in erosion area in patients with early rheumatoid arthritis treated with myocrisine. J Rheumatol. 1993 Feb;20(2):243–247. [PubMed]
  • Egsmose C, Lund B, Borg G, Pettersson H, Berg E, Brodin U, Trang L. Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5 year followup of a prospective double blind placebo controlled study. J Rheumatol. 1995 Dec;22(12):2208–2213. [PubMed]
  • Munro R, Hampson R, McEntegart A, Thomson EA, Madhok R, Capell H. Improved functional outcome in patients with early rheumatoid arthritis treated with intramuscular gold: results of a five year prospective study. Ann Rheum Dis. 1998 Feb;57(2):88–93. [PMC free article] [PubMed]
  • Tsakonas E, Fitzgerald AA, Fitzcharles MA, Cividino A, Thorne JC, M'Seffar A, Joseph L, Bombardier C, Esdaile JM. Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3 year followup on the hydroxychloroquine in early rheumatoid arthritis (HERA) study. J Rheumatol. 2000 Mar;27(3):623–629. [PubMed]
  • van der Heide A, Jacobs JW, Bijlsma JW, Heurkens AH, van Booma-Frankfort C, van der Veen MJ, Haanen HC, Hofman DM, van Albada-Kuipers GA, ter Borg EJ, et al. The effectiveness of early treatment with "second-line" antirheumatic drugs. A randomized, controlled trial. Ann Intern Med. 1996 Apr 15;124(8):699–707. [PubMed]

Figures and Tables

Figure 1
Early referral algorithm for newly diagnosed RA.

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