We also have the well-grounded premise that the earlier we start treating our RA patients, the better the outcome. The nature of the beast is that early in the game, many of our patients with recent onset of inflammatory arthritis do not permit themselves into being classified as RA according to the “one before” RA criteria set. In a Machiavellian way and with omniscience, we diagnose them as having RA, prescribe them methotrexate early in the course, and they do better. We also have some evidence that a similar early prescription of biologics would make them even better.
Experts on both sides of the Atlantic set out to make up new classification criteria based on how early RA had been being recognized in the best hands. Cleverly, they chose to define early RA as the decision to start methotrexate in a patient when other causes for inflammatory arthritis could be excluded. This exclusion, mind you, reminds us of the little footnote I alluded to earlier, under the table in the Behçet criteria. Going back to the ACR/EULAR criteria, the related manuscripts did not answer the nagging question of how many patients in daily practice with psoriasis and early onset arthritis are diagnosed as psoriatic arthritis when they present, only to find a year later that they have RA, or how many young women with synovitis of the small joints of the hand, Raynaud’s phenomenon, and a positive FANA are initially diagnosed with systemic lupus erythematosus and again turn out to have erosive RA at the end of a year’s follow-up. Nevertheless, the ACR/EULAR exercise tells me that there is strong agreement between the better (OK, the best!) rheumatologists on either side of the Atlantic as to when and how they start methotrexate in a patient with early onset inflammatory arthritis. If I start to do a trial for a new biologic or draw blood for research purposes, I will, in all probability, use these criteria. Then what is the issue? The issue, the incongruity, is to call these criteria RA criteria. They are, in fact, “When and if to start methotrexate in a patient with early onset inflammatory arthritis?” criteria. Why not call a spade a spade?
And why not, when confronted with a patient with an early onset of arthritis, simply say, “I am not certain whether you have rheumatoid arthritis, the bad disease you tell me your unfortunate next-door neighbor has, with which you tell me she is crippled and jobless. At this stage I do not have a sound and firm diagnosis. However, based on scientific evidence, if I prescribe methotrexate and perhaps other medications for you now, if you indeed do have RA, the chances are very good that you will benefit from what is prescribed. Meanwhile I will follow you closely, especially within the next few months, not only for the effects and side effects of what I prescribe but also for whether my initial classification—the diagnosis—of your condition was correct.” I am afraid it is as much our overestimation of our science as our underestimation of our patients’ cognitive abilities that keep us from such direct and honest dialogue. Perhaps we do not need to have a broken ankle to realize this.
