Introduction:
Early treatment provides a window of opportunity for treating patients with rheumatoid arthritis as it can halt the progression of the disease and improve outcomes. Signs and symptoms of this disease come way before clinical arthritis. The pre-arthritis phase follows specific symptoms; the most common among them is joint pain. Disease modulation during this pre-arthritis phase might prevent the occurrence of clinical arthritis. Recently, the best way to avoid the progression is to include patients with an increased risk of arthralgia and those more suspicious of developing arthritis.
What Is Arthralgia?
Arthralgia means joint pain without swelling. It has many underlying causative factors such as joint sprain or dislocation, tendinitis, hypothyroidism, or bone cancer.
What Is Arthritis?
Arthritis is inflammation of joints associated with pain, stiffness, and swelling. It can result from joint injury, obesity, osteoarthritis, or rheumatoid arthritis complications.
Not all joint pain requires emergency visits to the doctor. In mild to moderate pain, a routine treatment can help. However, when the joint pain is severe and includes redness, stiffness, and swelling, one should address these symptoms to the physician and undergo necessary blood tests as recommended.
What Are the Early Treatment Strategies for Rheumatoid Arthritis?
Early initiation of disease-modifying antirheumatic drugs is a cornerstone of current treatment strategies. Early treatment initiation is the strategy to minimize the effect of the disease. There is a confined period in which the disease is most susceptible to modify treatment effects. Although the exact period is unknown, it is assumed to be before the appearance of clinical arthritis.
Current treatment of rheumatoid arthritis deals with suppressing pain, stiffness, and swelling, but their ability to alter the course of the disease is limited.
How to Accurately Identify Individuals in the Pre-arthritis Phase?
It has been categorized into several phases based on current understandings of the risk factors associated with rheumatoid arthritis.
These phases include:
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Genetic and environmental risk factors.
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Autoimmunity is associated with arthritis.
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Joint pain without the clinical appearance of arthritis.
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Clinical arthritis.
Preventive trials have been made to assess treatment initiation in the following phases with the ultimate aim of preventing the onset of arthritis.
But the biggest challenge is how to identify patients in the pre-arthritis phase accurately and how to avoid over-treatment.
How Efficient Is Early Diagnosis and Treatment?
Success and evidence supporting early treatment initiation come from studies of patients with clinical arthritis. Providing prior treatment before the clinical onset of the disease is found efficacious. Starting immunosuppressants in the inductive phase is found beneficial in arthritis compared with no treatment. However, no such effect of disease-modifying antirheumatic drugs has been found in patients without clinical arthritis. Such patients should be treated with nonsteroidal anti-inflammatory drugs or painkillers to reduce pain and inflammation and should be monitored closely to check for developing clinical signs of arthritis.
What Are the Various Modes of Disease Prevention in the Healthcare Setting?
Disease prevention aims at reducing the risk and threats to patients' health and includes a wide range of procedures and interventions.
Prevention strategies are categorized into:
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Primary Prevention.
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Secondary Prevention.
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Tertiary Prevention.
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Primary prevention aims to prevent disease before its occurrence. It can be implied in all individuals, high-risk individuals as a result of some exposure (genetic or environmental), and in individuals with specific age groups.
Examples include Immunization, screening, and early treatment.
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Secondary prevention reduces the symptoms of the disease that has already occurred. For example, joint pain. In this process, disease progression is halted by detecting and treating the condition as soon as possible.
Example: Regular screening after the age of 50 years.
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Tertiary prevention aims to relieve the effects of persistent disease. It targets the clinical outcome of infection. Tertiary prevention occurs when the condition is developed and can no longer be prevented. Therefore, it aims at improving the quality of life.
Secondary interventions for patients who might progress to arthritis begin with identifying patients suffering from arthralgia. However, not all patients with arthralgia develop arthritis.
How to Identify Patients at Risk of Developing Arthritis?
Patients at increased risk of developing arthritis depend mainly on the healthcare setting.
Patients with arthralgia can be screened in primary or secondary healthcare settings.
In primary care settings, intervention can be performed on patients complaining of any musculoskeletal symptoms.
Patients with clinical arthritis represent only a small number of those with musculoskeletal symptoms and are referred to secondary care.
In secondary care, clinical expertise and disease patterns play an essential role in differentiating practices with arthralgia which can progress to arthritis with other types of arthralgia.
In general, not all patients with arthralgia are similar, and the probability of patients progressing from arthralgia to arthritis varies depending on various factors.
How to Diagnose Rheumatoid Arthritis?
In rheumatoid arthritis, anti-citrullinated protein or peptide antibody (ACPA) levels are elevated, and clinically anti-cyclic citrullinated peptide (ACCP) antibody is widely used to diagnose rheumatoid arthritis.
However, anti-citrullinated protein or peptide antibody (ACPA) levels alone can not be used in diagnosis.
Thus other potential biomarkers for predicting the progression include subclinical joint inflammation, detected by ultrasound or magnetic resonance imaging (MRI).
Increased levels of C-reactive protein can also predict arthritis development.
Blood tests and assessing physical abilities are other diagnostic tests.
How European League Against Rheumatism (EULAR) Defined Arthralgia Progressing to Arthritis?
EULAR stands for European league against rheumatism. The clinical definition consists of seven items from history taking and physical examination. This program includes clinical assessment, laboratory tests, ultrasound with power doppler of both hands, and radiographic evaluation of both hands and feet. All patients are evaluated after the baseline treatment and further follow-ups. The definition aims to rule out the high-risk people who are more likely to develop arthritis.
Conclusion:
The development of arthritis is a multistep process that takes many years before the appearance of clinical arthritis. The pre-arthritis phase is an opportunity phase where disease can be prevented from developing. Identifying correct patients where disease progression can be prevented is crucial. Several studies are being made to identify high-risk groups and populations are being tested, and trials are completed. However, treatment efficacy in the pre-arthritis phase has not been demonstrated. Differentiating people with arthralgia and at risk of developing arthritis can be made from the EULAR definition of arthralgia at risk of arthritis. This definition is a sensitive marker of arthritis development. Other diagnostic tests are also there that can indicate the occurrence of the disease. Thus early diagnosis and treatment play a chief role in managing the disease.
