A stitch in time saves nine…How early is early in Rheumatoid Arthritis?

July 3, 2011

Rheumatoid arthritis is a chronic autoimmune arthritis with destructive potential. It not only destroys joints but can also play havoc with one’s personal life, family life & career. As Rheumatologists, we have learnt over the last decade that the only way to conquer this deadly disease is to treat early & aggressively with DMARDs.

However, how early is early enough?

We are very much interested in knowing how early we should be treating RA with DMARDs for the best results. This period is the ‘window of opportunity’. Once missed, the prognosis would change drastically. Initially, this was thought to be 2 years from the onset of symptoms. Later, it was thought that diagnosis & treatment with DMARDs within 6 months from the onset of symptoms should be good enough to take care of the disease.

Michel PM van der Linden studied this ‘window of opportunity’ at the Leiden Early Arthritis Clinic. His group studied 1674 patients with RA over a period of 6 years for the level of improvement with DMARDs & joint destruction. They found that contrary to popular belief, 6 months is too long a period to be considered as the window of opportunity. 12 weeks was found to be the critical period. A delay of more than 12 weeks would mean a lesser chance of achieving a drug free remission & 1.3 times higher risk of joint destruction in the long run. What was very striking was the fact that the effect of the delay could not be nullified by a more potent medication strategy later. Treatment started in this phase had the best chance of inducing remission & reset the disease. The effect was seen for anti CCP positive as well as negative patients.

What this means is that any delay of more than 3 months form the onset of symptoms to the start of DMARDs would mean poor outcome in the long run. Where can this delay occur?
1) Patients taking time to seek help.
2) Time taken at the Family physicians level in diagnosing & referring patients to a Rheumatologists.
3) Time taken at the Rheumatologist level in getting an appointment.

The average delay in UK, Canada & the Netherlands was found to be 23 weeks, 17 weeks & 18.4 weeks respectively. A survey in the UK found that delay at the patient level was the main cause of delay. Hence, an earnest request from my side to anybody suffering from joint pain – please seek a Rheumatologist’s help at the earliest. You can take this quiz to know if you have early arthritis. Please do not underestimate any joint pain or swelling as a part of ageing or as rheumatism that would settle on its own. Seek an expert help & that could mean a whole new life for you in the long run!

References:
1)van der Linden, M. P. M., le Cessie, S., Raza, K., van der Woude, D., Knevel, R., Huizinga, T. W. J. and van der Helm-van Mil, A. H. M. (2010), Long-term impact of delay in assessment of patients with early arthritis. Arthritis & Rheumatism, 62: 3537–3546. doi: 10.1002/art.27692
2)Bykerk, V. and Emery, P. (2010), Delay in receiving rheumatology care leads to long-term harm. Arthritis & Rheumatism, 62: 3519–3521. doi: 10.1002/art.27691
3)Kumar K et al Delay in presentation to Primary care physician is the main reason why patients with Rheumatoid arthritis are seen late by Rheumatologists. Rheumatology (oxford) 2007;46:1438-40
4)Feldman DE et al Rapidity of rheumatology consultation for people in an early inflammatory arthritis cohort. Ann Rheum Dis 2009;68:1790-1.


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