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Rheumatoid arthritis diagnosis

November 30, 2015

The authors of the paper, published in Arthritis & Rheumatism, report that general practitioners diagnosed 79% of the 10,001 rheumatoid arthritis cases but only 27% of patients then saw a rheumatologist. Half of these patients were seen in the first three months and of these it emerges that only 17% received confirmation they were actually suffering from rheumatoid arthritis.

Rheumatologist, Boonen says, "The low referral rates of cases with suspected rheumatoid arthritis to rheumatologists is worrisome, especially when considering the discrepancy in diagnoses between the initial diagnosis by the non-rheumatologists and the following diagnosis by the rheumatologists."

Boonen recommends further research to confirm the findings and explore the wider implications of the study. ???If we really feel the window of opportunity for treatment of rheumatoid arthritis exists, rheumatologists should increase their efforts to raise diagnostic capabilities of first-line physicians towards early diagnosis and referral of suspected patients with rheumatoid arthritis".

biomedcentral/

Twenty patients with erosive psoriatic arthritis were enrolled to receive etanercept twice weekly for 24 weeks. Biomarkers were measured and clinical assessments performed at baseline, 2, 12 and 24 weeks. Gadolinium-enhanced magnetic resonance images were obtained at baseline and 24 weeks to measure bone marrow edema. All patients were given subcutaneous injections of etanercept, 25 mg twice weekly for 6 months. This study was approved by the Institutional Review Board at the University of Rochester Medical Center, and informed consent was obtained from all patients.

The study found that patients saw improvement in the 68 joints analyzed, including less swelling and pain, according to standard measures of joint function. Secondly, patients treated with anti-TNF therapy saw a dramatic drop in the median level of osteoclastic precursor cells (OCP) in patients' blood, from 24.5 OCP per million white blood cells to 7 (p = 0.006) after 6 months of treatment. The rapid decline in OCPs after anti-TNF therapy provides one explanation for the anti-erosive effects of TNF blockade in PsA.

A second, related explanation may be seen in the bone marrow edema results, albeit with limitations. Past studies have suggested that bone marrow edema predicts regions where severe bone erosions are soon to develop. To address this hypothesis, Schwarz and colleagues designed a study to assess the impact of anti-TNF therapy on the edema using gadolinium enhanced MR images. The longitudinal images provided researchers with an ???unparalleled view??? of the psoriatic joint, and the ability to accurately measure the borders of edema lesions in the bone marrow surrounding each joint.

The study found that edema volume decreased in 47 joints, indicating that the inflamed bone marrow was returning to its normal fatty content following therapy. However, the analysis also revealed an increase in edema-like lesions in 31 joints at 6 months. The team believes that those signals were caused by as yet unidentified changes in the bone marrow not related to bone marrow edema and osteoclast precursors, but further studies will be needed to confirm that.

???A simple blood test can determine a person's osteoclast precursor levels,??? Schwarz said. ???That should soon change medical practice as we can tell by OCP levels if a person has erosive disease. If those levels fail to drop immediately with anti-TNF therapy, that person is likely among the 30 percent of people who don't respond to etanercept. We can spare them the side effects and perhaps switch them to drugs like rituximab or abatacept, which are approved for rheumatoid arthritis patients that do not respond to anti-TNF therapy. While the blood test can tell you if you have PsA, it cannot tell which joints are affected. That feat has been achieved in this study for the first time with new MRI technology, which shows which joints have pre-erosive, osteoclast precursor lesions forming in the nearby bone marrow. These two tests, done in serial fashion, should allow for earlier diagnosis and more precise treatment of psoriatic erosive arthritis.???

urmc.rochester/