diagnostic criteria for rheumatoid arthritis

Last edited 09/2018

diagnostic criteria for rheumatoid arthritis

New classification criteria has been brought forward in 2010 by the American College of Rheumatology and European League Against Rheumatism.

Target population (Who should be tested?): Patients who
1) have at least 1 joint with definite clinical synovitis (swelling)*
2) with the synovitis not better explained by another disease **

score

Classification criteria for RA (score-based algorithm: add score of categories A-D; a score of 6/10 is needed for classification of a patient as having definite RA) ***

 

A. Joint involvement $

 

1. large joint||

0

2-10 large joints

1

1-3 small joints (with or without involvement of large joints) @

2

4-10 small joints (with or without involvement of large joints)

3

>10 joints (at least 1 small joint)****

5

B. Serology (at least 1 test result is needed for classification) ^^

 

Negative RF and negative ACPA

0

Low-positive RF or low-positive ACPA

2

High-positive RF or high-positive ACPA

3

C. Acute-phase reactants (at least 1 test result is needed for classification) &&

 

Normal CRP and normal ESR

0

Abnormal CRP or abnormal ESR

1

D. Duration of symptoms $$

 
< 6 weeks

0

>= 6 weeks

1

ACPA = anti-citrullinated protein antibody; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; RA = rheumatoid arthritis.


*- The criteria are aimed at classification of newly presenting patients. In addition, patients with erosive disease typical of RA with a history compatible with prior fulfillment of the 2010 criteria should be classified as having RA. Patients with long-standing disease, including those whose disease is inactive (with or without treatment), who, based on retrospectively available data, have previously fulfilled the 2010 criteria should be classified as having RA.

** - Differential diagnoses differ in patients with different presentations, but may include conditions such as systemic lupus erythematosus, psoriatic arthritis, and gout. If it is unclear about the relevant differential diagnoses to consider, an expert rheumatologist should be consulted

***-Although patients with a score of less than 6 out of 10 are not classifiable as having RA, their status can be re assessed, and the criteria might be fulfilled cumulatively over time.

$ - Joint involvement refers to any swollen or tender joint on examination, which may be confirmed by imaging evidence of synovitis. Distal interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints are excluded from assessment. Categories of joint distribution are classified according to the location and number of involved joints, with placement into the highest category possible based on the pattern of joint involvement.

||- "Large joints" refers to shoulders, elbows, hips, knees, and ankles.

@ - "Small joints" refers to the metacarpophalangeal joints, proximal interphalangeal joints, second to fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists.

**** - In this category, at least one of the involved joints must be a small joint; the other joints can include any combination of large and additional small joints, as well as other joints not specifically listed elsewhere (e.g., temporomandibular, acromioclavicular, sternoclavicular). ^^ - Negative refers to international unit values that are less than or equal to the upper limit of normal for the laboratory and assay; low positive refers to international unit values that are higher than the upper limit of normal but three or less times the upper limit of normal for the laboratory and assay; high positive refers to international unit values that are more than three times the upper limit of normal for the laboratory and assay. When rheumatoid factor information is only available as positive or negative, a positive result should be scored as low positive for rheumatoid factor.

&& - Normal/abnormal is determined by local laboratory standards.

$$ - Duration of symptoms refers to patient self-report of the duration of signs or symptoms of synovitis (e.g., pain, swelling, tenderness) of joints that are clinically involved at the time of assessment, regardless of treatment status.

Reference:

  1. Aletaha D et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-81.