Chronic Pain Syndromes: Current Concepts and Treatment Strategies _ _______________________________
2010 AMERICAN COLLEGE OF RHEUMATOLOGY/EUROPEAN LEAGUE AGAINST RHEUMATISM CLASSIFICATION CRITERIA FOR RHEUMATOID ARTHRITIS a Criteria Score Joint involvement 1 large joint b 0 2–10 large joints 1 1–3 small joints c (with or without involvement of large joints) 2 4–10 small joints (with or without involvement of large joints) 3 >10 joints (at least 1 small joint) 5 Serology (at least one test result needed for classification) 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 (at least one test result needed for classification) Normal CRP and normal ESR 0 Abnormal CRP or abnormal ESR 1 Duration of symptoms Less than six weeks 0 Six or more weeks 1 RF = rheumatoid factor; ACPA = anticitrullinated protein antibody; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate. a Target population: patients who have at least one joint with definite clinical synovitis in whom the synovitis is not better explained by another disease. b Large joints include shoulders, elbows, hips, knees, and ankles. c Small joints refers to the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists. Source: [158] Table 7
methotrexate [168]. The second trial produced similar results as the first trial [169]. Sarilumab may be use as monotherapy or in combination with methotrexate or other conventional DMARDs. The usual dose is 200 mg subcutaneously once every two weeks [36; 166]. For patients with early rheumatoid arthritis (less than six months in duration) who have never taken a DMARD, oral DMARD monotherapy (preferred agent: methotrexate) is recommended as first-line treatment [160]. Sulfasalazine is similarly effective, and leflunomide may provide comparable results [156; 161; 164]. In methotrexate- naïve patients with early rheumatoid arthritis, symptom response is similar between methotrexate and adalimumab or etanercept, and improvement in functional capacity is similar between methotrexate and adalimumab [161]. Adding predni- sone reduces radiographic progression and joint erosion but increases risk of adverse events. Biologic DMARDs are more effective than oral DMARDs in limiting radiographic evidence of progression [134; 156].
In patients with longstanding active disease, biologic DMARDs offer greater likelihood of remission than oral agents and there- fore are often the approach used [134; 156; 161]. Combining two biologic DMARDs does not improve disease activity, functional capacity, or symptom response, yet it does increase the risk of serious adverse events. However, if oral DMARDs are used, a combination of two or three agents is more effective than monotherapy [134; 156]. In patients with longstanding active disease requiring a change in therapy, biologic DMARDs are preferred over oral DMARDs [134; 156; 160]. The combination of a biologic DMARD and methotrexate provides greater symptom reduc- tion than either agent alone without increasing the risk of serious adverse events.
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