ACR 2010 Rheumatoid Arthritis Diagnostic Criteria
RA diagnosis is made if score ≥ 6 based on the following 4 criteria (Patient receives one score for each criteria)
Joint involvement
  • Joint must be swollen or tender. May be confirmed on imaging.
  • Joints excluded from assessment - DIP joints, 1st carpometacarpal joints (involved in OA), and 1st metatarsophalangeal joints (involved in gout)
Finding Score
1 large joint
  • Large joint - shoulders, elbows, hips, knees, and ankles
0
2 - 10 large joints 1
1 - 3 small joints
  • Small joint - metacarpophalangeal joints, PIP joints, 2nd through 5th metatarsophalangeal joints, thumb interphalangeal joints, and wrists
2
4 - 10 small joints 3
> 10 joints with at least 1 small joint
  • may also include TMJ, AC joint, etc.
5
Serology
  • Either RF or ACPA (Anti-CCP antibodies) is needed for classification
  • Low positive - low-positive refers to IU values that are higher than the upper limits of normal (ULN) but ≤ 3 times the ULN for the laboratory and assay
  • High positive - refers to IU values that are > 3 times the ULN for the laboratory and assay
  • Where rheumatoid factor (RF) information is only available as positive or negative, a positive result should be scored as low-positive for RF
Finding Score
Negative RF and negative ACPA 0
Low-positive RF or low-positive ACPA 2
High-positive RF or high-positive ACPA 3
Acute-phase Reactants
Finding Score
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
Duration of symptoms
  • Refers to patient self-report of the duration of signs or symptoms of synovitis (e.g., pain, swelling, tenderness) of joints that are clinically involved at the time of assessment, regardless of treatment status
Finding Score
< 6 weeks 0
≥ 6 weeks 1






  • Reference [10]
EULAR 2013 Recommendations for the treatment of RA
Phase I - Initial therapy
  • Methotrexate or combo of csDMARDs +/- Low-dose corticosteroids +/- Leflunomide or Sulfasalazine (alone or in combination)
    • Low-dose corticosteroids defined as a dose of 7.5mg/day or less of prednisone or equivalent
    • csDMARD combinations combination should include methotrexate unless it is contraindicated. The most frequently used combination is methotrexate + sulfasalazine + hydroxychloroquine.
    • csDMARDs - methotrexate, sulfasalazine, hydroxychloroquine, leflunomide
      • *csDMARD stands for "conventional, synthetic disease-modifying antirheumatic drug"

  • If there is no change after 3 months, or target is not achieved at 6 months, then Phase II
Phase II - Adjust therapy for non/incomplete responders
  • Prognostically unfavorable factors present - Add biological agent

  • Prognostically unfavorable factors NOT present - Change to second csDMARD strategy
    • Second csDMARD therapy - Leflunomide, sulfasalazine, methotrexate alone or in combination (ideally with addition of corticosteroids as above)
    • Combinations of leflunomide or sulfasalazine without methotrexate have not been well-studied
    • For patients who do not achieve targets on second csDMARD therapy, add biological agent
Phase III - Adjust therapy for non/incomplete responders to Phase II
  • Change biological agent
    • Replace any first biological drug with any other biological drug
    • Tumor Necrosis Factor (TNF) inhibitors may be replaced with another TNF inhibitor
    • Continue csDMARD
    • Tofacitinib +/- csDMARD may be considered in patients who do not respond to biological medications


Reference [24]
Condition Treatment recommendation
Tuberculosis (TB) Before starting biologic or tofacitinib therapy:
  • Screen all patients for TB
  • Latent TB - treat TB for at least 1 month before starting therapy
  • Active TB - patients should complete TB treatment before starting therapy
Congestive Heart Failure
  • Use csDMARDs or non-TNF biologic or tofacitinib over TNF inhibitors
  • If CHF worsens on TNF inhibitor, switch to one of these other therapies
Hepatitis B
  • Untreated patients should be referred for treatment before starting immunosuppressive therapy
  • If patient is receiving or has received effective treatment, then recommendations are the same as those in patients without Hepatitis B
Hepatitis C
  • If patient is receiving or has received effective treatment, then recommendations are the same as those in patients without Hepatitis C
  • In patients who have not been treated effectively, use csDMARDs over TNF inhibitors
Melanoma
(current or past)
  • Use csDMARDs over biologicals or tofacitinib
Non-melanoma skin cancer
(current or past)
  • Use csDMARDs over biologicals or tofacitinib
Lymphoproliferative disorder
(previously-treated)
  • Rituximab is preferred over TNF inhibitors
  • Use csDMARDs or abatacept or tocilizumab over TNF inhibitors
Solid organ tumor
(previously-treated)
  • Recommendations are the same as those in patients without a history of solid organ tumor
Previous serious infection
  • Use csDMARDs over TNF inhibitors
  • Use abatacept over TNF inhibitors



Component Measurement
Number of tender joints 28 joints are measured
(10 MCP joints; 10 PIP joints; 2 wrists, 2 elbow; 2 shoulder; 2 knee)
Number of swollen joints 28 joints are measured
(10 MCP joints; 10 PIP joints; 2 wrists, 2 elbow; 2 shoulder; 2 knee)
ESR or C-reactive protein Either one can be used
Global assessment of health Patients makes a mark on a 10 cm line
with 1 being "very bad" and 10 being "very good"

DAS28 score Disease activity
< 2.6 Remission
2.6 - 3.2 Low disease activity
3.2 - 5.1 Moderate disease activity
> 5.1 High disease activity