Patients with clinically suspect joint pain have an increased risk of developing rheumatoid arthritis
INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, causing pain and disability. It is more common in older people, but it has a high incidence in young people as well. It affects both men and women. In the very early stages of the disease people might have joint pain (also called arthralgia) without joint swelling (arthritis).
WHAT DID THE AUTHORS HOPE TO FIND?
It is thought that treating people in the very early stages of rheumatoid arthritis might help to stop the disease becoming chronic. But at the moment, it is hard to work out who will go on to develop full rheumatoid arthritis. The authors hoped to find whether people with joint pain without arthritis (also called ‘clinically suspect arthralgia’, sometimes shortened to CSA) are in the early stages of rheumatoid arthritis.
WHO WAS STUDIED?
The study looked at 150 people. Everyone in the study had recent joint pain in their hands or feet without joint swelling (less than a year), and had seen a rheumatologist who thought the pain was suspicious. None of the people had been treated with disease-modifying antirheumatic drugs (often shortened to DMARDs) or glucocorticoids (steroid medicines) before the project or during follow-up.
HOW WAS THE STUDY CONDUCTED?
The study took place at one centre in the Netherlands, where people with joint pain are seen in a special clinic. Information is collected at each person’s first visit with the rheumatologist, and then at least 3 follow-up appointments over 2 years. Everyone had an MRI (short for magnetic resonance imaging) of their most painful hand and foot to see if there was inflammation inside the joint. Blood tests were done to see whether people had antibodies that are known to be related to rheumatoid arthritis (called anticitrullinated peptide antibodies, or ACPA). ACPA is found in half of patients with rheumatoid arthritis, and can help to distinguish it from other types of arthritis. The tests also looked for markers of high levels of inflammation in the blood called C-reactive
protein, or CRP. At each visit everyone in the study also had physical examinations to look for arthritis in their joints, and they completed questionnaires about their quality of life and ability to work and carry out everyday tasks.
WHAT WERE THE MAIN FINDINGS?
About 17% of all people with clinically suspect arthralgia had developed clinical arthritis within 1 year of first coming to the clinic, and mostly within 4–5 months. This shows that the period of having clinically suspect arthralgia before it turns into arthritis is quite short.
Nearly a third of people who had been shown to have inflammation in the MRI of their hand or foot developed arthritis within 1 year. Only a small minority (6%) of patients without inflammation visible on their MRI developed arthritis. This means that MRI might be useful in the very early stages to both identify people who have an increased risk of arthritis, and also to rule out imminent arthritis. People with joint pain who tested positive for ACPA, those with increased blood markers of inflammation, younger people and people with pain in a greater number of joints were at increased risk. This information might help to identify people who will go on to develop rheumatoid arthritis.
ARE THESE FINDINGS NEW?
Yes. Looking at people with early joint pain is a novel approach, and this is the first study that has investigated MRI findings in people in the early symptomatic phase on such a large scale.
ARE THERE ANY LIMITATIONS?
This study took place in only one group of people at one clinic. Before it can be decided if MRI is useful in all people with early joint pain, the results should be confirmed in other groups. In addition, identifying people with ‘clinically suspect arthralgia’ is based on the clinical expertise of the rheumatologist. This means that it can be subjective, and might vary between different doctors.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
A EULAR taskforce recently developed a definition of arthralgia suspicious for progression to RA.1
More studies are required to see whether this definition can be used to predict who will go on to develop arthritis. If it is possible to accurately identify people at risk, then trials can reveal whether treating people in the very early phase can prevent them developing clinical arthritis, or reduce the impact or severity of the disease. Some trials looking at this are already underway in several European countries.
WHAT DOES THIS MEAN FOR ME?
More studies are needed, but in the future imaging and blood tests might be used to work out whether your joint pain will develop into full arthritis, and if you need to be treated.
At the moment, people with joint pain that a rheumatologist suspects might develop into rheumatoid arthritis are seen regularly in an outpatient clinic. It is not yet common to start treatment before arthritis is present unless you are involved in a clinical trial. If you have concerns about painful joints, you should speak to your doctor.
FUTHER READING
1. van Steenbergen, HW. et al. EULAR definition of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis 2017;76(3):491–496. doi: 10.1136/annrheumdis-2016-209846.
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Date prepared: October 2016
Summary based on research article published on: 6 October 2016
From: van Steenbergen, HW. et al. Clinical factors, anticitrullinated peptide antibodies and MRI-detected subclinical inflammation in relation to progression from clinically suspect arthralgia to arthritis. Ann Rheum Dis 2016;75:1824–30. doi: 10.1136/annrheumdis-2015-208138.
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