Early Treatment of Rheumatoid Arthritis Is an Elusive Goal

The catchphrase for rheumatoid arthritis (RA) treatment has become “early and aggressive." It is the best remedy that medicine has today for the management of RA. There has been much debate about what constitutes “aggressive.” This may not matter if it is not possible to treat “early.”

Significance of early diagnosis
Early treatment of RA is not possible without early diagnosis. Reliable sources report that treatment may be necessary from as early as several weeks to six months after the onset of symptoms. The goal is clear: to identify RA in time to use disease-modifying anti-rheumatic drugs (DMARDs) to stop the progression of the disease or forestall permanent damage.

Recent evidence shows RA may spread through the body via unseen synovial fibroblasts, making early treatment even more significant. Diagnostic criteria have shown poor performance for the diagnosis of early RA in the past and The American College of Rheumatology (ACR) revised criteria have yet to be tested.

Barriers to early diagnosis include fear, ignorance, and skepticism
Fear is understandable. The early symptoms of RA can be severely painful, but also can seem bizarre enough to engage in denial for fear of a horrifying diagnosis. Patients may hope that the condition will improve so they defer medical inquiry.

Ignorance of early RA is pervasive in the general public and may not be much better among general practitioners (GPs). RA is often diagnosed first as a series of its specific symptom-associated diagnoses such as iritis, tendonitis, dislocations, sprains, Felty’s syndrome, or pleurisy. If specific diagnoses such as those are not documented, a general diagnosis such as fibromyalgia is usually given. Median delay before an RA diagnosis may be as long as nine months.

There is no clear criteria which can be used by GPs to identify early RA. Commonly, patients are screened using sed rate or rheumatoid factor, both of which are poor indicators of early RA. The new guidelines of the ACR may permit earlier treatment of some RA patients who have been referred to a rheumatologist, but are inadequate to help GPs identify probable RA in order to refer. Early RA easily falls outside of even the new guidelines. Many common first symptoms of RA are not on even part of the guidelines.

Skepticism is not unique to RA; doctors have to treat several so-called “invisible illnesses.” The same bizarre presentation that causes early RA patients to fear seeking a diagnosis can confuse a GP also. It is understandable that unless they are trained otherwise, doctors may look with skepticism upon the collection of complaints of a patient with early RA.

Unfortunately, the skepticism of a trusted primary care physician can cause shame in a patient which will lead to further delay in diagnosis. The patient may not return for some time although the symptoms continue. The combined barriers of embarrassment, fear, time off from work, and expense of medical appointments create too great of an obstacle to overcome.

Suggestions for increasing early diagnosis
Obviously, we all hope for the development of better tests to objectively identify early RA. However, there are a few ways to increase early diagnosis immediately even without them:

• GPs could be better informed of common symptoms of early RA.
• Doctors could be strongly encouraged to add anti-CCP tests to their screening of suspected RA.
• More doctors could take advantage of the internet to learn about what RA looks like via RA blogs, forums, etc.
• When examining a patient with dubious symptoms, doctors should follow the golden rule of medicine: treat this patient the way you would want your mother treated.
• A campaign for general awareness of RA ought to educate the public about the symptoms of RA and the serious nature of the disease.
   

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Kelly Young is the author of the Rheumatoid Arthritis Warrior website.