New Classfication Criteria of RA

New Classfication Criteria of RA

Sung-Hwan Park

Seoul St. Mary’s Hospital

Catholic University of Korea

Rheumatoid arthritis

Common autoimmune disease characterized by persistent inflammation of joints resulting

in progressive destruction of cartilage and bone

History of Rheumatoid arthritis

Sydenham : first case report in 1676

Example of RA-like disease: Early 17^th, Deutch Art

Garrod, 1859: Rheumatoid, Gout and Rheumatic fever Charles, 1957: describe RA

Etiology원인

Pathogenesis of RA

Management of RA

Early, accurate diagnosis Early DMARD therapy

Strive for remission in all patients

Monitor carefully for treatment toxicities Consider and treat comorbid conditions

Breedveld, F C et al. Ann Rheum Dis 2004;63:627-633

Criteria for RA(1987, ACR)

1. Morning stiffness lasting more than 1 hour

2. Arthritis of 3 or more joints – soft tissue swelling or joint effusion

3. Arthritis of hand – wrist, MCP, PIP 4. Symmetric arthritis

5. Rheumatoid nodules

6. Serum rheumatoid factor 7. Radiographic changes

• 4 of the 7 criteria are required

• 1-4 ; must present for at least 6 weeks

• 2-5 ; must be observed by physician

Radiologic findings of RA

• Periarticular soft tissue swelling

• Periarticular osteoporosis

• Marginal erosion

• Symmetric joint space narrowing

• Subchondral cyst

• subluxation

Radiologic findings of RA

Bone erosion

Radiologic findings of RA

Lack of sensitivity in early disease The classification criteria set :

widespread international use to define RA

; well accepted as providing the benchmark for disease definition

newly presenting patients with undifferentiated synovitis

1)identify the subset at high risk of chronicity and erosive damage

2) be used as a basis for initiating disease

modifying therapy

Classification criteria vs Diagnostic criteria

not on developing diagnostic criteria

or providing a referral tool for primary care physicians.

separate body of work is needed to develop

such tools, which may be informed by classification criteria.

to facilitate the study of persons at earlier stages of the disease.

Phase 1:

DMARD therapy in a patients with early undifferentiated synovitis

• Phase 2 :

laboratory factors deemed to be important in influencing the probability of developing

“persistent inflammatory and/or erosive arthritis

Phase ^{3 :}

2 to develop a scoring system that would be applicable to newly presenting patients with

undifferentiated inflammatory arthritis to permit identification of those with a high probability of developing persistent and/or erosive RA.

Large joint

Joint involvement

Excluded from Assessment

5

3

2

1

3

1

1 3

2

3

5

 42, Male

 Polyarthralgia for 3 mo : both hand PIP, feet MTP, shoulder, and wrist

 Morning stiffness (+) : 2 hours

 Medication Hx : none,

 Tender J. : 8 Swollen J. count : 7

 RF : 66.9 IU/mL, Anti CCP Ab : 54.2 U/mL

 ESR : 59mm/h, CRP : 2.9mg/dL

1) Joint involvement;(4-10 small jt); 3 2) Serology ;3

3) Acute phase reactant; 1 4) Duration 1

• 5/7; RA(1987 criteria)

• 8/10; definite RA

MTX 20mg

• 40, Female

- Both MTP joint pain for 6 months

- Recently developed Lt. 3^rd PIP joint pain ( 1 month ago)

• morning stiffness (+) : > 1 hour

• Medication Hx : none

• TJ count : 7, SJ count : 6

• ESR : 30 mm/hr, CRP : 0.43 mg/dL

• RF : 137.2 IU/mL, Anti CCP Ab : 65.5 IU/mL

1) >4 small jt Joint ; 3 2) Serology ; 3

3) Acute phase reactant; 1 4) Duration 1

• 5/7; RA(1987 criteria)

• 8/10; definite RA

Clinical remission

Radiographic remission

Take home message

Early, accurate diagnosis Early DMARD therapy

The treatment target is clinical remission Monitor carefully for treatment toxicities Consider and treat comorbid conditions