Neobook — clinical reference

Joint damage begins within the first 3 months of disease onset. There is a ‘window of opportunity’ where early aggressive therapy of RA can suppress inflammation before irreversible joint destruction has occurred.^[6-8] Early diagnosis and initiation of DMARD therapy are therefore critical. The 2010 American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) classification criteria are a useful reference (Table 1).^[9,10] Recently, there has been recognition that some patients have joint symptoms but no clinically apparent synovitis. Patients with three or more of seven clinical features have an increased risk of progression to RA and are termed ‘clinically suspect arthralgia’ (CSA), and should be referred to a rheumatologist (Table 2).^[11] A validation study showed that this test is useful, with a sensitivity of 84%.^[12]

Table 1. 2010 ACR/EULAR RA classification criteria*
Criteria		Score^†
Joints	1 large joint	0
	2 - 10 large joints^‡	1
	1 - 3 small joints^§	2
	4 - 10 small joints	3
	>10 joints	5
Serology	Negative RF and negative anti-CCP	0
	Low-positive RF or low-positive ACPA (≤3 times ULN)	2
	High-positive RF or high-positive ACPA (>3 times ULN)	3
Acute-phase reactants	Normal CRP and ESR	0
Acute-phase reactants	Abnormal CRP or ESR	1
Symptom duration	<6 weeks	0
Symptom duration	≥6 weeks	1
ACR = American College of Rheumatology; EULAR = European Alliance of Associations for Rheumatology; RA = rheumatoid arthritis; RF = rheumatoid factor; anti-CCP = anti-cyclic citrullinated peptide; ACPA = anti-citrullinated peptide antibody; ULN = upper limit of normal; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate. *Patients must: (i) have at least 1 joint with definite synovitis (swelling), (ii) with the synovitis not better explained by another disease. ^†A score of ≥6/10 is needed for classification of a patient as having definite RA. ^‡‘Large joints’ refers to shoulders, elbows, hips, knees and ankles. ^§‘Small joints’ refers to the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists

Table 2. Clinical features of joint pain suspicious for progression to RA (‘clinically suspect arthralgia’)*
History	Joint symptoms of recent onset (duration <1 year) Symptoms located in MCP joints Duration of morning stiffness ≥60 minutes Most severe symptoms present in the early morning
Physical examination	Presence of a first-degree relative with RA Difficulty with making a fist Positive squeeze test of MCP joints
RA = rheumatoid arthritis; MCP = metacarpophalangeal. *Patients with a positive definition (≥3/7 parameters present) should be referred to a rheumatologist.

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Tarr, G., Govind, N., Seboka, M., Gardiner, E., & Hodkinson, B. (2024). South African Rheumatism and Arthritis Association 2024 updated guidelines for the management of rheumatoid arthritis. South African Medical Journal, 114(9), e2598.