In the future, rheumatoid arthritis, or RA, might be detected before its symptoms become evident, and early cases could be stopped in their tracks, if recent research pans out.

Scientists presented findings at the American College of Rheumatology, or ACR, Annual Scientific Meeting in Atlanta Nov. 6 to 11 on two studies that could affect early detection and treatment of the autoimmune disease.

Early detection
One study focused on a new classification system to identify potential RA cases. Using criteria in the 2010 ACR/European League Against Rheumatism Rheumatoid Arthritis classification might make it possible to spot early warning signs of RA before people are diagnosed.

“If our goal is to achieve lifelong, drug-free remission, it may require someone to intervene and treat a person very early in the process – maybe even earlier than waiting until someone comes into the clinic,” says Jason R. Kolfenbach, MD, the study’s lead author and an assistant professor at the University of Colorado Denver School of Medicine in Aurora.

The new criteria, introduced as a replacement for those established in 1987, are intended to better identify cases of early disease. The new system classifies patients on a zero-to-10 scale. People are considered to have RA if they score six or higher, which means, among other things, that they have an inflamed joint capsule in at least one area that can’t be explained by another condition.

Colorado researchers used these criteria to test 1,790 patients taking part in an ongoing RA study of symptoms, joints and biomarkers of people at risk for developing the disease. That analysis identified 21 patients who have not been diagnosed with RA but appear to have early risk factors, including multiple swollen and tender joints.

Of those 21, 11 also had high levels of C-reactive protein, which indicates inflammation is present, six tested positive for rheumatoid factor and one was positive for more specific antibodies commonly seen in RA patients.

“We’ve been prospectively following a lot of these people since 2002. Now we can sub-identify those who might be at higher risk for developing what we might consider as RA,” Dr. Kolfenbach says. “We aren’t using [the criteria] to diagnose a patient, but to classify them so we can do initial analysis and find out the long-term implications.”

Researchers plan to track these subjects over time to see if they develop full-blown RA. Results of the study might some day lead to an early screening test for the disease, they say.

“Right now we can’t tell from looking at [subjects] how far away they might be from the diagnosis of RA in the clinical setting, or if they will avoid the diagnosis altogether,” Dr. Kolfenbach says. “We hope that nobody develops this, but if we capture them just before diagnosis or significantly before and identify factors that provide a high level of certainty of persistent disease, then we can intervene and treat, even before patients present to the doctor.”

Early Treatment
Another study shows that newly diagnosed RA patients and those suspected of having the disease but not yet diagnosed may be able to achieve remission – meaning they have no symptoms or disease activity – if they take methotrexate and prednisone for four months.

“The idea is that, in the earliest phase of the disease, patients who have limited signs and symptoms of what may progress to full-blown RA have the best chance to go into permanent remission after treatment with a progressive combination of anti-rheumatic drugs,” says Cornelia Allaart, MD, PhD, an associate professor of rheumatology at Leiden University Medical Center in the Netherlands.

Dr. Allaart and her research team studied 261 patients who had recently developed RA and 161 with “undifferentiated” arthritis, meaning they have arthritis in more than one joint and are at risk of getting a full-blown case. All were taking 60 milligrams a day of prednisone, which was reduced over seven weeks to 7.5 mg a day, as well as 25 milligrams of methotrexate a week.

One hundred fifty-three RA patients, 58.6 percent of the newly diagnosed group, achieved remission, as did 107 people with undifferentiated arthritis – 66.5 percent of that group. In all, 63 percent of the participants went into remission and all reported functioning better in daily life.

“These percentages are much higher than previously recorded in trials and cohorts, but then again, that may be because we are aiming for that by including patients with milder symptoms that were normally left out,” Dr. Allaart says.

Although the results are encouraging, Dr. Allaart says the real test comes when the medication is tapered and stopped in the patients who achieved remission. In an earlier study, her research team showed that methotrexate can be effective in postponing development of RA from the undifferentiated arthritis stage, but when the medication was stopped, patients relapsed and the disease progressed. Researchers want to see if the addition of prednisone results in a different outcome.  

For now, Dr. Allaart says patients should consult a doctor as soon as they have complaints about their joints.

“Doctors have to establish as soon as possible whether there is arthritis,” Dr. Allaart says. “They should treat each arthritis as a potential emergency, since there is evidence that early start of treatment not only makes sure that the patients will feel better more quickly, but will also prevent severe joint damage progression, which determines functioning in the long run.

“It is my dream to change the face of rheumatoid arthritis itself,” she adds. “It has become known, for lack of effective therapies until recently, as a chronic, progressively debilitating disease. But if we are early enough and start treatment with the most effective drugs, we can look at RA as being an acute, treatable illness, and start looking for a potential cure in the next decade.”