Counseling Points - October 2007 - (Page 8)

Table 1. ACR Criteria for Classification of Rheumatoid Arthritis3 Criteria Morning stiffness* Arthritis of 3 or more joints* Definition Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement At least 3 joint areas simultaneously have had soft tissue swelling of fluid (not boney overgrowth alone) observed by a physician. The 14 possible areas are right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle, and metatarsophalangeal (MTP) joints At least 1 area swollen (as defined above) in a wrist, MCP, or PIP joint Simultaneous involvement of the same joint areas on both sides of the body (bilateral involvement of the PIPs, MCPs, or MTPs is acceptable without absolute symmetry) Subcutaneous nodules, over bony prominences, or extensor surfaces, or in juxta-articular regions, observed by a physician Demonstration of abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in <5% of control subjects Radiographic changes typical of RA on post anterior hand and wrist radiographs, which must include erosions or unequivocal bony decalcifications localized or in most marked adjacent to the involved joints (osteoarthritic changes alone do not qualify) lupus. In addition, the clinician should assess the patient for the presence of extra-articular disease, radiographic damage, and co-morbid conditions, and perform a careful, qualitative joint exam that assesses swelling, redness, and warmth of joints and muscle wasting or deformity.3,10 Diagnostic Tests and Radiography There are a number of laboratory tests and radiographic procedures that may aid in the diagnosis of RA. No single test, histologic finding, or radiographic characteristic confirms that a patient has RA; rather, clinicians use a number of findings over a period of time to determine if the disease is present.10 One common laboratory test detects an antibody called rheumatoid factor (RF), which is found in more than 85% of adults with RA.1 Concentration of RF has been demonstrated to correlate with severe and unremitting disease, nodules, and extra-articular lesions.4 However, it is important to note that the presence of RF is indicative of but not specific to RA. Some patients with classic RA never test positive for RF, while up to 5% of healthy individuals and 10% to 20% of individuals over age 65 may exhibit positive values.4 RF can also be elevated in a number of other diseases, such as scleroderma, systemic lupus, and polymyositis, and in chronic infections such as hepatitis C, endocarditis, and syphilis.4 Another test that is used to detect RA is erythrocyte sedimentation rate (ESR), which is a measurement of the rate at which red blood cells settle. The ESR level correlates with the degree of synovial inflammation and is useful to assess inflammatory activity in patients.1 Additionally, measurement of C-reactive protein (CRP) may be useful to evaluate inflammation. A relatively new assay that is becoming more widely used to identify RA is the anticyclic citrullinated peptide (CCP) test, which detects specific autoantibodies associated with RA.20 This test is more specific than an RF test; in addition, CCP can be identified in a significant number of patients who have a negative RF test. CCP antibodies may be detected in approximately 8 Arthritis of hand joints* Symmetric arthritis* Rheumatoid nodules Serum rheumatoid factor Radiographic changes *Must be present a minimum of 6 weeks. ACR=American College of Rheumatology. • Symmetric arthritis • Rheumatoid nodules • Positive serum rheumatoid factor • Radiographic changes In addition, if the four criteria are met, they must have been present for a minimum of 6 weeks. During the initial visit, the patient should be asked about degree of pain, duration of stiffness and fatigue, and any functional limitations he/she experiences.3 RA also should be differentiated from other disorders that may share some of the same symptoms, such as polyarticular gout, fibromyalgia, viral arthritis, and COUNSELING POINTS™

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Counseling Points - October 2007 Welcome Introduction Overview of RA RA Morbidity and Mortality RA Costs and Quality of Life RA Risk Factors Pathophysiology of RA Diagnosis and Natural History of RA Diagnostic Tests and Radiography Natural History and Progression of RA Disease Management Treatment Strategies Summary Continuing Education Posttest Evaluation Form

Counseling Points - October 2007

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