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EXTENDED REPORT

EULAR de

finition ofarthr algiasuspiciousfor progressiontorheuma toidarthritis

Hanna Wvan Steenbergen,

1

Daniel Aletaha,

2

Liesbeth JJ Beaart-van deVoorde,

1

Elisabeth Brouwer,

3

CatalinC odreanu,

4

Bernard Combe,

5

João EF onseca,

6,7

MereteL Hetland,

8,9

FrancesHumby ,

10

ToreKKvien,

11

Karin Niedermann,

12

LauraNuño,

13

Sue Oliver,

14 15

Karim Raza,

16,17

Dirkjan vanSchaardenburg,

18

Georg Schett,

19

Liesbeth DeSmet,

1

Gabriella Szücs,

20

Jirí Vencovský,

21

Piotr Wiland,

22

Maarten deW it,

23

RobertL Landewé,

24

Annette HM vander Helm-vanMil

1,25

ABSTRACT

BackgroundDuring thetr ansitiontorheumatoid

arthritis (RA)many patients passthrougha phase characterisedbythe presence ofs ymptomswithout clinically apparentsynovitis. Thesesymptomsarenot well-characterised.Thistaskforceaimed tode fine the clinical characteristicsofpatientswith arthralgia whoare considereda triskforRA bye xperts basedon their clinical experience.

MethodsThe taskforceconsistedof 18

rheumatologists,1methodologis t,2 patients,3health professionalsand1 resear chfello w.Theprocesshad threephases .InphaseI, alis tof parameters considered characteristicforclinicallysusp ectarth ralgia (CSA)was derived;the most importantparametersw ere selectedby a three-phasedDelphiapproa ch.In phaseII,theexperts evaluated50 exis tingpatientsonpaper, classified them as CSA/no-CSAandindica tedtheir levelofcon fidence.

A provisionalsetofpar ameters was derived.Thiswas

studiedfor validation inphaseIII, where all rheumatologistscollectedpatients withand withoutCSA fromtheir outpatient clinics.

ResultsTheco mprehensivelistconsisted of55

parameters,ofwhich1 6w ereconside redmos timportant .

A multivariablemodelbasedonth edatafromph aseII

identified sevenrelev antparameters:sym ptomduration <1y ear,symptom sofmetacarpophala ngea l(MCP)joints, morningstif fnessduration≥60 min,mos tsevere symptomsinearly morn ing,first-degreerelati vewithRA, difficultywi thmakingafistan dpositi vesqueezetestof

MCPj oints.InphaseII I,th ecombinati onofthes e

parameterswasaccur ateinid entifyingpatients wit h arthralgiawhowere consider edatrisk ofdevelopingRA (areaunde rtherecei veroper atingcharacteris ticcurve

0.92,95%CI 0.87to 0.9 6).Testc har acteristicsfo r

differentcut-off pointsweredete rmined. ConclusionsA setofc lini calcharacterist icsforpatients withart hralgiawhoareatrisk ofprogr essionto RAwas established.

INTRODUCTION

The developmentofr heumatoid arthritis(RA)isa

multisteppr ocess.TheEuropean LeagueAgains t

Rheumatism(EULAR) study groupdifferentia tedthe followingphases:(1) presence ofgenetic andenvironmentalrisk factors forRA,(2) sy stemicautoimmunity associatedwithR A,(3) symptomswithout clinicalarthritis, (4)unclassi fied arthritis

andfinally (5)R A. 1

The symptomaticphasepre-

ceding clinicalarthritis isthe firstopportunity to clinically recognisepatients whoarea trisk forpro- gressionto RA. Incontrast tothe otherphasesthat havebeens tudiede xtensively,this phaseislesswell studied.While afe ws tudiesreportedon symptoms experiencedby patients inthisphaseand ontheir impacton dailylife, 2-4 clinical characteristicsthat arespeci fic forthis phaseha ve notyetbeenidenti- fied bya consensus-basedappr oach. 156

This situ-

ationhampers theconduct ofs tudiesand clinical trials inthis phaseof thedisease. Ithas beensho wn thatearly initiation ofdisease-modifyingantirheu- maticdrug (DMARD)tr eatment inRAismore effectivein modulating theerosive andpersis ting natureofR Acompar edwithdelay edinitiationof

DMARD treatment.

7-9

Hence, interventionsinthe

initial clinicalphase ofthe disease,which precedes the onsetof clinicalarthritis, may bemor eeffective in reducingtherisk ofdisease persistence andthe developmentof damage. 10

However,studiesto

addressthis requir etheinclusionofhomogeneous sets ofpa tients.

Clinical expertise,whichincludes pattern recog-

nition, guidesdecision sindailypr actice andhas also beenused asr eference forthedevelopmentof severaltoolsor criteriain thefield ofr heumato- logy. 11-14

Patientswithclinically suspectarthr algia

(CSA)ha vearticularsymptoms withoutsignsof arthritisand are consideredtobe atincreased risk for progressiontoRA. 15

Hence, theidenti fication

of thepr esenceofCSA isbased onclinicalexper - tise. Recentdata revealedtha tpatientswithCSA constituteonly asmall percentage ofall patients with arthralgiawhovisit ther heumatology out- patientclinic forthe firsttime (≂7%), andtha ta proportionofpa tientswith CSAdidindeed pro- gressto RA duringfollow-up( ≂20%). 16

It wasalso

suggestedtha tclinicale xperiencewas accurateto distinguishpa tientswitharthralgia at riskofRA fromother patients witharthralgia(OR 55).In par- ticular,only aminori tyof patientswhopr esented van Steenbergen HW , et al. Ann Rheum Dis 2017;
:491-496. doi:10.1136/annrheumdis-2016-209846

To cite:

van Steenbergen HW,

Aletaha D, Beaart-van de

Voorde LJJ

, et al . Ann Rheum Dis 2017;
76
:491-496.

Handling editor

Hans WJ

Bijlsma

ŹAdditional material is

published online only. To view please visit the journal online (h t t p d x d o i o r g 1 0 1 1 3 6 a n n r h e u m d i s 2 0 1 6 2 0 9 8 4 6

For numbered affiliations see

end of article.

Correspondence to

Dr Annette H M van der

Helm-van Mil, Department of

Rheumatology, Leiden

University Medical Center,

P.O. Box 9600, Leiden

2300 RC, The Netherlands;

AvdHelm@lumc.nl

Received 5 May 2016

Revised 18 August 2016

Accepted 17 September 2016

Published Online First

6 October 2016

Clinical and epidemiological research

491van Steenbergen HW, et al. Ann Rheum Dis 2017;:491-496. doi:10.1136/annrheumdis-2016-209846

on October 23, 2023 by guest. Protected by copyright.http://ard.bmj.com/Ann Rheum Dis: first published as 10.1136/annrheumdis-2016-209846 on 6 O

ctober 2016. Downloaded from with arthralgiaandsubseq uentlydev elopedRAw erenotr ecog- nised bythe rheuma tologist. 17 Although theconcept ofC SAis appropriatefor usein clinical practice,adr awba ckisitssubjectivity,whichmay result from differencesin pra cticeandexperience.Therefor e,the phenotype of CSAneedsto bede fined. Thistaskfor ceaimedtoidentify a combinationof clinicalfea tures thatbestchara cterisepatients with arthralgiawhoar ea triskofR Aaccordingto ane xpert multidisciplinary groupofEur opeanr heumatologists,other health professionalsandpa tients.This approachw assimilar to thatwhich ledto thede finition ofin flammatoryba ckpain,a definition whichw assubsequentlyintegra tedin theAssessment of SpondyloArthritisinterna tionalSocietyclassificationcri- teria. 18 19 The taskforceintendedto derive aset ofclinicalpara- meters toenable theinclusion ofhomogeneous setsof patients in subsequents tudies.Itwas considered inappropriateto usethe phrase'classificationcriteria 'for thepr oductas,basically, classi- ficationconcerns testing thepresenceor absenceof adisease. CSAis notin itselfa disease,but acombina tionof symptoms and signs.It was anticipatedthat clinicalcharacteris ticsalone areinsuf ficient predictiveforRA, that acombinationof clinical and otherfa ctors(eg,autoantibodies,imaging results) are neces- sary toidentify patients withimminentRA andtha tthe derived clinical definition canla terbecomepartof criteriafor imminent RA.Thus insum, thepr esenttaskfor ceaimed todefine arthral- gia atriskfor RA.

METHODS

Expert committee

The expertcommitteecomprised 18rheum atologis ts,1 metho- dologist(RL, whow asalso oneoftherheum atologis ts),2 nurse specialists,1 physiother apist,2patientsand1r esearch fellow, originatingfr om15European countries.The targetpopulations wererheuma tologistsandhealthprofessionalsworkingin sec- ondary care.

Three-phasedprocess

The processconsisted ofthreephases andtwo meetings.Expert opinion wasther eference. Perphaseconsensuswas obtained beforepr oceedingtothene xtphase.

Phase I

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