Change of plans
This post was begun last week. The original title of this post was ACR: Change the Diagnosis Guidelines! (It is still that in my laptop.) However, Monday morning I learned that late on Sunday, The American College of Rheumatology in cooperation with the European League Against Rheumatism (EULAR) released new guidelines for diagnosis of Rheumatoid Arthritis.
The ACR is meeting right now in Philadelphia in what they call their 2009 Scientific Meeting. Until two days ago, the guidelines used were those adopted in 1987. Please see this post on the ACR guidelines for Rheumatoid Arthritis diagnosis where you can see why I called the 1987 ACR guidelines “moldy.”
Tension building over criteria for Rheumatoid Arthritis diagnosis
I sensed that a tension was building over the last few years as more studies showed how crucial early treatment is for Rheumatoid Arthritis. In Can I Delay Treatment for Rheumatoid Arthritis, part 2, I quoted University of Kansas Hospital researchers who say 60% of people with RA have joint damage within 2 years so they recommend that disease modifying treatment begin within 3 months of symptoms. Tension is unyielding between that perspective and the current guidelines. Patients often feel that their doctors have made that early treatment impossible by failing to diagnose Rheumatoid Arthritis until irreversible damage is obvious.
The 1987 criteria have been part of the problem because they do not usually allow for early diagnosis since they describe more advanced disease. How can patients get early treatment unless they get early diagnosis? And how can they get early diagnosis when the diagnostic standards are a description of advanced disease? If you have read much of this blog (or many others), then you know the sad results to this dilemma.
In the rheumatology doctor’s own words
Dr. Alan J. Silman, a Manchester University rheumatologist, says, “Satisfying the 1987 criteria is bad news. No one waits till the disease becomes erosive to start disease modifying therapy.” Well, we wish that no one waited. But that is not yet the case.
Missing the mark from the beginning
Last week, I reviewed the book What to Do When the Doctor Says It’s Rheumatoid Arthritis. I could not believe what Doctor Fischer says on page 35 about the true purpose of those guidelines. “ACR criteria can be helpful in making a diagnosis, though some doctors can detect RA even if a patient doesn’t fully meet these guidelines… In fact, the ACR originally created the criteria to provide uniform research standards, allowing doctors and medical experts to do research, reports, and clinical studies among patients with comparable symptoms.”
Did you get that? He says those guidelines were never intended for use in regular clinical diagnosis! So, how did those 1987 guidelines become the gold standard for diagnosis in the eyes of practicing rheumatologists around the world? What were those rheumatologists taught in years of training? No wonder so many books written by rheumatologists are wrong about so many facts about RA. No wonder it’s so tough to get answers about Rheumatoid Arthritis.
The big question: will RA diagnosis improve?
Will the new diagnostic standard facilitate earlier diagnosis of Rheumatoid Arthritis? It may take months to sort that out. We’ll begin to examine that here next time. Get a peek at the actual criteria using the link below to Mitchel Zoler’s blog.
Hurray for Photojournalism!
Special thanks to Mitchel Zoler, Pennsylvania medical reporter for his reporting from the ACR meeting. His report is brief and clear. You can read it here. He has posted a photograph of the new guidelines which is extremely helpful since the ACR has not posted them on their website yet.
- How is Rheumatoid Arthritis Diagnosed? Part 1
- What Is the First symptom of Rheumatoid Arthritis?
- Parvovirus B19 and Rheumatoid Arthritis: Who is the real fraud?