American College of Rheumatology Redefines Rheumatoid Arthritis, Part 3

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new ACR RA diagnostic criteria

Will the enthusiasm of Rheumatoid Arthritis patients be short-lived?

Reactions have varied to the new diagnosis guidelines which the American College of Rheumatology (ACR) released this week for Rheumatoid Arthritis. Is it good news for RA’ers? People who have Rheumatoid Arthritis often feel such a need for change that any news is good news. But I am only cautiously optimistic.

What bothers me about the new RA diagnostic criteria?

The new ACR guidelines raise two obvious issues:

Definition of joint involvement

First, how will the doctors define “joint involvement”? If they will continue to use the same methods used since 1987, patients may not fare better. One doctor’s opinion of “involved” may not be the same as another. Will redness and swelling be required? Or are pain, weakness, stiffness, and disability sufficient? Will the patient’s report of joint involvement suffice? Or will the doctor’s ability to manually manipulate a joint in an office setting call the joint “functional”?

Emphasis on blood tests

Second, the ACR portrays the new guidelines as a move to de-emphasize serology. I do not see how this can be so. Between the Rf/anti-CCP “Serology” result and the ESR/CRP “Acute phase reactants” result, a possible four out of six total points required can be acquired by blood work alone. That is 66% of a positive result.

And, conversely, it would be very difficult to reach a score of 6 without positive blood tests. More than 10 joints would have to be sufficiently “involved” before a diagnosis could be obtained. As many as 37% of RA patients have “normal” blood tests all of the time.

An RA patient’s viewpoint

As far as I can tell, a committee of rheumatologists developed the new guidelines over the last couple of years. They have included categories which are effective for classification from their viewpoint. They have removed items from the previous set of guidelines which are symptoms that are not verifiable in a clinical setting, such as fatigue, frequent fevers, and morning stiffness, which can only be confirmed by patients. As a person living with Rheumatoid Arthritis, my viewpoint is clearly distinct from theirs.

My Idea: what would I add to the new guidelines?

Consideration of several typical symptoms of Rheumatoid Arthritis could provide an opportunity to insure that an early RA diagnosis is not missed. What about adding a fifth section to the chart? You could score 2 points total if any two RA symptoms such as these are present:

Symmetry of joint involvement
Constant low-grade fevers
Morning stiffness
Eye inflammation
Rheumatoid nodules
Lack of appetite
Evidence of heredity of RA

What else must be considered?

First, there is tension between over-diagnosis and under-diagnosis. Under-diagnosis of Rheumatoid Arthritis can have obvious devastating consequences. But, over-diagnosis could mean exposing a person to un-necessary risk of DMARD treatment.

Second, there is the question of medical “practice.” Different doctors can use the same guidelines and obtain different results because they interpret both the evidence and the guidelines in diverse ways. Soon we’ll examine the ACR’s proposal for doctors’ use of the new guidelines in practice, called a decision tree.

These are my initial impressions based upon what the ACR has made available to the public. I will remain cautiously optimistic because the ACR has said that they hope to improve Rheumatoid Arthritis diagnosis with their new guidelines. I too hope that diagnosis of RA can be accomplished earlier, with more accuracy.

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Kelly Young. All rights reserved.

This entry was posted on Thursday, October 22nd, 2009 at 8:07 am and is filed under The Real Rheumatoid Disease. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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