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ACR2013: What clues suggest impending rheumatoid arthritis in a patient with stiffness and joint problems? A comparative study offers an answer, and another suggests that sleep problems are an important clue to severity of RA.
Given the importance of recognizing and treating rheumatoid arthritis (RA) as quickly as possible, what symptoms should raise red flags about RA in a physician's mind? Members of a European Union League Against Rheumatism (EULAR) study group from the Netherlands and the UK have produced some answers, after conducting focus groups with patients who have arthralgia and are at risk of RA and others newly diagnosed with the disease.
The study involved 15 patients with arthralgia and positive titers for anti-citrullinated protein (anti-CCP) antibodies and 11 newly diagnosed with RA based on 2010 criteria. Analysis of similarities and differences produced these clues to emerging RA, as described in an abstract for the presentation:
• Both antibody-positive patients with arthralgia and those with early RA described pain and tingling in the joints, but the arthralgia patients described it as "bothersome" or "annoying," while early RA patients said it intensified to "excruciating" shortly before diagnosis.
• Both groups noticed swelling, but arthralgia patients described swelling as intermittent, while early RA patients said that the swelling had changed significantly, intensifying and becoming symmetric or translocating (changes that often triggered the initial consultation with the doctor).
• Fatigue and sleeping difficulties are the first symptoms that patients with early RA recall in the course of their disease. These are the dominant problem for patients with arthralgia, including"intense and troubling" pain at night.
In a separate report, rheumatologists from two hospitals in Pennsylvania and from New York University School of Medicine in New York reveal that a single question about getting a good night's sleep can be a powerful clue to the severity of RA.
Martin Bergman MD and his coworkers assessed 200 patients in a single rheumatology practice using numerous self- and physician-reported scales of symptoms and functional status, including the question "Over the past week, were you able to get a good night's sleep?"
Sleep quality, as judged from responses to that single question, showed a direct and linear relationship to levels of disease severity as judged by the DAS28(ESR), CDAI, SDAI and RAPID3 scales, they report. Patients who say they sleep well are very likely to have low disease activity, and conversely those who sleep poorly are unlikely to be in a low disease state. Another study by the same team finds that this holds true for a variety of rheumatologic conditions.