Diagnostic criteria rheumatoid arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

These are the most commonly used criteria for the diagnosis of rheumatoid arthritis. The criteria were summarized in an excellent article by Linda Jean Sekhon, DHSc, PA-C in the Journal of the American Academy of Physicians Assistants (http://www.jaapa.com/using-the-new-acr-criteria-for-early-diagnosis-of-rheumatoid-arthritis/article/213222/3/)The actual guidelines can be also be sen at the American College of Rheumatology website. (http://www.rheumatology.org)

In September 2010, the collaboration between the American College of Rheumatology and the European League Against Rheumatism produced three phases of recommended changes to the 1987 criteria.

The first phase, led by EULAR, 
consisted of reviewing existing data collected from patients with early arthritis. This was an attempt to identify patients at high risk for more persistent erosive arthritis considered to be RA by the 1987 criteria. The next phase, led by the ACR, focused on reaching a consensus among practicing rheumatologists to identify the most important factors in predicting the likelihood that a patient will experience chronic joint damage. In phase three, the first two phases were integrated and a scoring system to define disease was established.

The new criteria define definite RA based on the presence of synovitis in at least one joint, the absence of an alternative diagnosis that better explains the presence of synovitis, and a score of 6 or higher out of 10 from individual scores in four domains.

The first domain refers to any swollen or tender joint found on clinical evaluation and assigns a score between 0 and 5 based on the following criteria:

One large joint (0)

Two to ten large joints (1)

One to three small joints (2)

Four to ten small joints (3)

Greater than 10 joints with at least one small joint 

Categories of joint distribution in this domain are classified according to the location and number of involved joints.

Placement into the highest category possible is based on the pattern of joint involvement in which at least one of the involved joints must be a small joint. Large joints refer to shoulders, elbows, hips, knees, and ankles. Small joints refer to the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists. Joints excluded from this domain include distal interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints.

The second domain refers to serologic abnormality and assigns a score between 0 and 3. This is based on the following criteria:

Neither RF nor anti-CCP antibody positive (0)

At least one test (RF or anti-CCP antibody) low positive titer(2)

 At least one test high positive titer (3).

Definition of a negative RF refers to international unit (IU) values that are less than or equal to the upper limit of normal (ULN) for the laboratory and assay. A low positive refers to IU values that are greater than the ULN but less than 3 times the ULN for the laboratory and assay. High positive refers to IU values that are 3 times the ULN for the laboratory and assay. Where RF information is available only as positive or negative, a positive result should be scored as low positive for RF. Determination of anti-CCP antibody positivity is determined by local laboratory standards.

The next domain is duration of synovitis. This category assigns a score of either 0 or 1 according to the patient self-report of the duration of signs or symptoms of synovitis. Signs or symptoms refer to pain, swelling, and/or tenderness of joints that are clinically involved at the time of assessment. This is based on the following criteria:

Duration of symptoms less than 6 weeks (0)

Duration of symptoms 6 weeks or longer (1).

The final domain refers to acute phase response and assigns a score of 0 or 1. This score is based on the results of the ESR and CRP. Scores are assigned based on the following criteria:

Neither ESR nor CRP abnormal (0)

Abnormal ESR or abnormal CRP (1).

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