Doctors Strive for Quicker Diagnosis of Rheumatoid Arthritis

When John Cush, MD, began treating people with rheumatoid arthritis (RA) in the 1980s, doctors considered the disease to be detected early if they diagnosed it for up to 8 years after patients noticed. their symptoms for the first time.

“Eight years!” says Cush, rheumatologist at UT Southwestern Medical Center in Dallas. “That’s an atrocious definition today.”

Ten years ago, the average time to diagnosis fell to less than 3 years. Today, thanks to better research and better training of physicians and patients, that window is reduced to just 6 months.

Yet it is still too slow.

“It’s really better than 10 years ago,” Cush says. But even today, “the average person is not diagnosed early enough”.

Research shows that in some cases, RA can lead to joint damage in as little as 12 to 16 weeks. This is why it is so important to see a specialist who can diagnose your RA and get you started on the right treatment plan.

But confusing symptoms, lack of definitive diagnostic tests, long waits for specialists, and other obstacles can sometimes get in the way.

Difficult diagnosis

The three characteristics of a joint with RA seem deceptively simple: painful, tender, and swollen.

But without a specialist in RA, says Stanford Shoor, MD, clinical professor of medicine and rheumatology at Stanford University, the path to a correct diagnosis can be anything but simple.

For example, RA can look like osteoarthritis, a much more common disease that results from mechanical wear and tear instead of the faulty immune response that causes RA. Or it could reflect symptoms of carpal tunnel syndrome, which is usually triggered by repetitive movements, or lupus, another autoimmune disease.

Recent injuries or viral illnesses, such as a cold or the flu, can cause short-term RA-like pain and swelling. Therefore, in order to rule out these causes, the American College of Rheumatology needs 6 weeks of symptoms to make a diagnosis of RA.

And while many of your persistent symptoms indicate RA, “that doesn’t mean you have it,” says Shoor. “It just means you should see a rheumatologist.

Continued

On the other hand, any persistent joint pain could turn out to be RA, even if it’s not in a common place.

Cush, of UT Southwestern, once saw a patient with long-term pain in the thumb at the joint closest to the thumbnail, which is very unusual for RA.

“She evolved over a year to be someone who had six or more swollen joints and eventually had very severe rheumatoid arthritis that required surgeries. Earlier diagnosis and treatment, Cush says, may have spared his serious damage.

Primary care physicians, often the first stop for patients, can also delay diagnosis, especially if they don’t see much RA. It could waste precious weeks.

And by the time your doctor finally sends you to a specialist, you’ll likely be in another long wait. A national survey found that it takes on average almost 45 days to get a first appointment with a rheumatologist. It was much longer than any other specialty and 2.5 times the wait to see a cardiologist.

Another problem is that some people just don’t ask for help early enough, Cush says. They may postpone a doctor’s visit, self-treat with over-the-counter pain relievers, or dismiss their symptoms as normal aging.

This delay could be costly, Cush says. In 40% of cases, RA results in incapacity for work of some type within 10 years of diagnosis. And research shows that the ideal “treatment window” for RA seems to be in the first 3 months.

“Patients treated earlier are less likely to have joint surgery. They are less likely to have a disability, ”Cush says. “They are less likely to be hospitalized later in their illness.”

Symptoms to watch out for

There are some benchmarks that can help you and your doctor determine if you have RA, says Stanford’s Shoor. The first is simple: do you have pain in one or more joints?

The second is tenderness. It means pain when you move or push on a joint. “You can test this yourself,” Cush says. “Press down on the knuckle of the finger with the other hand and see if it’s tender. Normally, this shouldn’t be the case. For larger joints, like the knee, move it through normal range of motion to see if it hurts more.

Continued

The location of the gaskets also matters. The three most common for RA are the wrist, elbow, and the joint where each finger meets your hand (metacarpophalangeal joint or MCP).

That doesn’t mean you can’t get RA in other joints. But problems in these joints, as well as in your ankle, are more likely to suggest RA, in part because they are rarely affected by osteoarthritis.

In contrast, says Shoor, symptoms in the knee, shoulder, or middle finger joint (proximal interphalangeal) could also indicate osteoarthritis or RA.

Another clue is the number of joints involved. RA typically hits more than four. And its symptoms tend to be symmetrical. This means that if your right index finger is swollen, tender, and painful, you will likely have similar symptoms on the fingers or wrist on the opposite side.

But the most telling symptom may be any unexplained joint pain that lasts for weeks. If you notice this, it’s probably time to talk to a doctor, ideally a rheumatologist.

In fact, Shoor says, talking to your doctor may be the most beneficial thing you can do for RA, even after your diagnosis.

Research shows that the success of long-term RA treatment has little to do with fancy imaging, biomarkers, or blood tests. The key factor is something much simpler: good communication.

These studies show that seeing your doctor more often and constantly adjusting your medication is essential to manage RA. Lab tests, however sharp, have surprisingly little effect, say Cush and Shoor.

This research has led to new treatment guidelines that doctors call “treat-to-target,” or T2T, in which you set a treatment goal based on pain levels with your rheumatologist and then work closely together to get there. This is now the standard approach for many rheumatologists.

In fact, Shoor says, perhaps one of the most powerful weapons against RA is yourself.

Sources

John Cush, MD, rheumatologist, UT Southwestern Medical Center, Dallas.

Stanford Shoor, MD, clinical professor of medicine and rheumatology, Stanford University.

Journal of Internal Medicine: “Treatment delays for patients with new-onset rheumatoid arthritis presenting to an Australian early-onset arthritis clinic.”

University of Wisconsin Medicine: “Comparison of Rheumatoid Arthritis and Osteoarthritis”.

Rheumatology: “Symptoms Associated with Inflammatory Arthritis Are Common in the Primary Care Population: Joint Symptoms Survey Results.”

UpToDate: “Epidemiology, Risk Factors and Possible Causes of Rheumatoid Arthritis.”

Athenahealth: “The doctor will see you … someday.”


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