In people who develop symptoms of inflammatory arthritis, early diagnosis and treatment can have a significant impact on the course of disease—in some cases even preventing deformity and loss of function from rheumatoid arthritis (RA), according to an article in the December issue of JCR: Journal of Clinical Rheumatology. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, and pharmacy.
Prompt specialist evaluation by a rheumatologist—within the first few weeks after symptoms appear—provides the best chance of avoiding progression to RA and restoring lost function, according to the article by Dr. Edith Villeneuve and colleagues of University of Leeds, U.K.
Early Diagnosis and Treatment Can Improve Outcomes of RA—or Even Prevent It
Rheumatologists in the United States and Europe are working to raise awareness of the need for early diagnosis and treatment of inflammatory arthritis (joint pain with signs of inflammation, such as swelling and redness). But to do that, they'll have to overturn some outdated but persistent myths. Many people still believe that arthritis is a disease affecting only elderly people, that there is no effective treatment, that it inevitably leads to severe deformity and disability, but does not increase the risk of death.
These myths may have been partly true in the past, but not anymore. "Over the last decade, significant advances have been made, and the natural history of arthritis is changing," Dr. Villenueve and coauthors write. "Effective treatment is now available for many conditions that were previously regarded as untreatable."
However, it's essential to start treatment in the early stages—before permanent damage occurs. "Although we now have effective therapies to treat inflammation, we are still unable to act on established structural damage," according to the authors. "Consequently, if treatment is delayed, the cumulative effects of untreated inflammation on function are only partially reversible following treatment."
Earlier evaluation by a specialist is critical. Current guidelines recommend that patients be referred to and seen by a rheumatologist, ideally no longer than 6 weeks after symptoms appear. At their clinic in Leeds, Dr. Villenueve and colleagues encourage early specialist evaluation of all patients with inflammatory arthritis.
Rheumatologists have the expertise to identify patients at greatest risk of progressive RA, who may benefit from newer treatment approaches. Informed and judicious use of laboratory and imaging tests can overcome the difficulties of recognizing RA in its early stages. Conventional x-rays aren't of much help—they may not show any abnormalities until the disease process is quite advanced. In certain situations, magnetic resonance imaging and ultrasound may provide useful information in the early stages.
Dr. Villenueve and colleagues follow a "step-up" approach to treatment, starting with simple treatments like pain-relieving drugs and proceeding to other more advanced treatments as needed. Intra-articular (inside the joint) steroid injections play a useful role. More than half of patients achieve significant improvement in their arthritis symptoms after steroid injection.
If symptoms don't get better, patients move on to treatment with disease-modifying antirheumatic drugs (DMARDS) in an effort to delay or halt the progression of RA. Today, the goal of DMARD therapy is nothing less than to achieve remission—"a state with no apparent disease activity but also without ongoing structural damage"—with the possibility of restoring lost function. Dr. Villenueve and colleagues outline recent research confirming that lasting remission is a possibility for at least some patients with early RA.
The next step in research is the possibility of preventing RA. Newer biologic treatments are effective in reducing the rate of progressive arthritis, especially when started early—within three months after initial symptoms. Dr. Villenueve and colleagues, along with other rheumatology research groups, have been developing and testing other preventive strategies, with encouraging preliminary results.
"Over the last decade, significant advances have been made, and the natural history of arthritis is changing," Dr. Villenueve and co-authors write. They hope their paper will contribute to increasing the number of patients who receive prompt specialist evaluation for symptoms of inflammatory arthritis—thus maximizing their chances of avoiding pain, deformity, and disability from progressive RA.
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