Features of early diagnosis of rheumatoid arthritis

Features of early diagnosis of rheumatoid arthritis

Rheumatoid arthritis (RA) is one of the most common rheumatic diseases. Its features are a continuously progressive course, leading to patient disability, significant comorbidity and a decrease in life expectancy by an average of 10 years [1]. Therefore, it is important to establish this diagnosis as early as possible for early initiation of adequate therapy. For a long time, physicians used the criteria developed by the ACR in 1987 [2]. But these criteria (Table 1) make it possible to verify RA at an advanced or late stage, when the possibilities of therapy are significantly missed. In 2010, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed [3] new criteria for diagnosing RA, allowing this diagnosis to be made at an earlier stage (Table 2 ). But, despite modern advances in the study of this disease, diagnosis in the early stages of RA still faces difficulties.

We present a clinical observation. Patient B., 38 years old.

For the first time I consulted a rheumatologist with complaints of pain and swelling in the joints over the past 2 months. Pain is predominantly of a mechanical nature (during physical activity, in the evening) in both knee joints, the right ankle joint, and sometimes small joints of the hands. Swelling in the left knee joint, right ankle joint. Mild morning stiffness (20–30 min). Objectively: signs of synovitis in the left knee joint, right ankle joint. There are no other changes. From laboratory tests, only a general blood test: hemoglobin - 163 g/l, leukocytes - 6.1x109/l, leukoformula - without deviations, ESR - 11 mm/h, platelets - 207x109/l. X-ray examination was not performed. Based on the predominantly mechanical nature of the pain, damage to large joints, and the absence of inflammatory changes in the general blood test, the rheumatologist made a preliminary diagnosis: “Osteoarthritis.” But to exclude the onset of other rheumatic diseases, additional laboratory and instrumental examinations were prescribed: detection of sexually transmitted infections, proteinogram, CRP, RF, ACCP, CEC, immunoglobulins, radiography of the knee joints, small joints of the hands and feet. I would like to draw attention to the fact that normal ESR, CRP, and proteinogram should not prevent the diagnosis of RA, because, according to the literature, in the first 2–3 months. disease, these indicators are normal in at least 50% of patients [4]. The patient is prescribed diclofenac 100 mg/day. On a follow-up visit, the patient noted the effectiveness of NSAIDs (diclofenac) in the form of a decrease in pain intensity and a slight decrease in swelling in the joints. An additional study revealed the following changes: proteinogram - a slight increase in the content of α1 and α2 globulins (5.8 and 13%); a slight increase in the level of CRP - up to 7.30 mg/l (normal - 0-5 mg/l); a slight increase in RF – up to 45.10 IU/ml (normal – 0–30 IU/ml); increase in ACCP - up to 859 U/ml (normal - no more than 20 U/ml). No changes were detected on radiographs. In accordance with the new classification criteria for RA in 2010, the patient has 6 points (arthritis of 2 large joints, highly positive ACCP, elevated CRP levels, duration of symptoms ≥ 6 weeks), which allows a diagnosis of “Early RA”. Detection of ACCP in blood serum [5] serves as a predictor of the development of RA in healthy people (OR 15.9) and in patients with early undifferentiated arthritis; Moreover, the presence of a high titer of ACCP is a prognostically unfavorable factor: a marker of severe erosive joint damage in RA. This requires early administration of basic therapy with rapid selection of an effective dose [6]. The drug of first choice is methotrexate. In addition to diclofenac therapy, the patient was prescribed methotrexate for subcutaneous administration once a week. at a dose of 10 mg, it is recommended to monitor effectiveness and tolerability every 3–4 weeks, and if necessary, increase the dose of methotrexate. After 2 weeks After starting methotrexate therapy, the patient complained of swelling (Fig. 1, 2) and pain in the small joints of the hands. The patient was discontinued from diclofenac and prescribed nimesulide (Nise®) 100 mg twice a day after meals.

While taking nimesulide, after 3 days the patient noted positive clinical dynamics in the form of a decrease in swelling, stiffness and pain in the small joints of the hands. The nonsteroidal anti-inflammatory drug (NSAID) nimesulide has established itself as a drug with a pronounced analgesic and anti-inflammatory effect in various rheumatic diseases; it belongs to the group of anti-inflammatory drugs with moderate selectivity [7], due to which it is less likely to cause dyspepsia and asymptomatic ulcers. Nimesulide has been shown to be highly effective not only for RA, but also for gout, ankylosing spondylitis, osteoarthritis, enthesitis, bursitis and tendinitis, and acute pain in the lower back; for postoperative pain relief [8–10]. This may be due to the presence of a central analgesic effect in addition to the main mechanism – COX-2 blockade [8]. Thus, this drug combines high efficacy with good tolerability. In addition to the options for the onset of RA that are more familiar to doctors (symmetrical polyarthritis with a gradual (over several months) increase in pain and stiffness, mainly in the small joints of the hands; acute polyarthritis with predominant damage to the joints of the hands and feet, severe morning stiffness), there are the following options for the onset of RA [ 11]: − mono- or oligoarthritis of the knee or shoulder joints, followed by rapid involvement of the small joints of the hands and feet, which was observed in the given clinical case; − acute monoarthritis of large joints, reminiscent of septic or microcrystalline arthritis; − acute oligo- or polyarthritis with systemic symptoms (febrile fever, lymphadenopathy, hepatosplenomegaly). More often observed in young patients (resembles Still's disease in adults); − palindromic rheumatism. Characterized by recurrent attacks of acute symmetrical polyarthritis of the joints of the hands, less often of the knee and elbow joints, lasting up to several hours or days, followed by complete recovery; − recurrent bursitis and tenosynovitis, usually of the wrist joints; − acute polyarthritis in elderly people with multiple lesions of small and large joints, severe pain, diffuse swelling and limited joint mobility. Received the name “RS3PE syndrome” (remitting seronegative symmetric synovitis with pitting edema - remitting seronegative symmetric synovitis with cushion-shaped edema); − generalized myalgia, stiffness, depression, bilateral carpal tunnel syndrome, weight loss. Usually observed in old age. Reminds me of polymyalgia rheumatica. The appearance of characteristic clinical signs of RA is noted later. When studying the frequency of various variants of the onset of RA [12], the following data were obtained: in patients under 45 years of age, the disease more often begins with damage to large joints, in people over 45 years of age – with small joints. The most frequently identified variants were: asymmetric mono- and oligoarthritis; symmetrical damage to large joints; symmetrical arthritis of small joints of the hands and feet; polyarthritis of the reactive type. Thus, the onset of RA may have a varied clinical picture (involvement of not only small but also large joints, mono- and oligoarthritis); at the onset there may be no laboratory activity (increased ESR, CRP level), therefore such patients require laboratory examination for RF and ACCP, X-ray examination of joints and dynamic observation by a rheumatologist.

Healthcare of Mogilev

In the absence of special treatment, RA is prone to long-term persistence of inflammatory activity and gradual destruction of joint structures and periarticular tissues, which during the first 5 years of the disease leads more than 40% of patients to disability.

For more than 20 years, the 1987 American College of Rheumatology criteria, which are presented in Table No. 1, have been used to diagnose RA.

Table 1. Diagnostic criteria for rheumatoid arthritis in 1987

(Arnett et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar;31(3):315-24.)

However, these criteria have now lost their relevance, since in the first 6 months of the disease they make it possible to establish a diagnosis of rheumatoid arthritis in 20-40% of the population, which, according to current concepts, is not suitable for timely and effective treatment. For this reason, these criteria were revised in 2010. (Table 2)

Tab. 2. 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification diagnostic criteria for rheumatoid arthritis

New criteria allow starting therapy during the period of its maximum effectiveness (the first 3 months from the onset of the disease) and achieving remission of the disease.

Another important condition for effective treatment of RA is the early referral of patients to a rheumatologist.