“People with rheumatoid arthritis (RA) usually present with stiffness and joint pain, most frequently of the hands and feet, sometimes accompanied by swelling,” explains Paul Emery, Arthritis Research UK Professor of Rheumatology at the Leeds Institute of Rheumatic and Musculoskeletal Medicine of the University of Leeds. “In the early stages these symptoms respond well to anti-inflammatories, which can delay RA detection. But if the symptoms are due to arthritis, the stiffness will return once anti-inflammatories are ceased. In this case, the person will need to see their GP and obtain an immediate referral for urgent specialist assessment.”


Diagnosis and treatment

A diagnosis of RA is made on the basis of medical history, physical examination and blood tests, as well imaging investigations (which include ultrasound and sometimes MRI, in addition to X rays) that allow assessment joint inflammation and damage.
Emery says: “Detecting the condition early is important for at least two reasons. The sooner patients are diagnosed and start treatment, the lower their risk of suffering extensive damage to joints, blood vessels and bones. Additionally, there is good evidence from real-world data that early treatment is associated with a one-off chance of an increased rate of remission and improved patient outcomes.
“The idea is to identify patients with a likelihood of persistent disease as soon as possible, and start therapy, usually with methotrexate and if required the short-term use of steroids. Those who don’t respond may be offered biologic drugs.”


Multidisciplinary approach

A benefit of early RA detection is that support from a multidisciplinary team can be provided sooner. The condition affects people psychologically as well as physically – the British Society for Rheumatology reports that over 10 per cent experience depression, and up to 90 per cent develop foot problems that limit their ability to move around. A multidisciplinary approach is therefore key. An RA care team will usually include a rheumatologist, a rheumatology nurse specialist, an occupational therapist, a podiatrist and a physiotherapist.


Anti-CCP antibodies

Thanks to exciting new advances, RA management has moved a step further, and doctors can now aim to “treat people before they actually get the full-blown condition,” says Emery. It is possible to identify individuals who are likely to develop RA, even if they don’t have the characteristic symptoms of the disease. This is done by looking for the presence in the body of antibodies known as anti-CCP. These auto-antibodies may be present up to several years before rheumatoid arthritis develops, but increase significantly just before the onset of symptoms. The vast majority of people who test positive for anti-CCP will go on to develop RA, but low levels of the antibody without other risk factors have a very low risk of and a slow conversion to clinical disease. Thus, once these patients are identified, it is essential they have a full risk assessment, including blood, imaging, (ultrasound and MRI) and possibly genetic tests. They require specialist care, which may include drugs that help stabilise the disease and prevent its progression.