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EULAR diagnostic recommendations geared to primary care physicians

EULAR diagnostic recommendations geared to primary care physicians

New European League Against Rheumatism (EULAR) recommendations for the diagnosis of knee osteoarthritis (OA) are expected to provide clinicians with a solid foundation of criteria for disease management and be particularly useful for primary care physicians. The guidelines were issued at EULAR's 2009 Annual Congress, held recently in Copenhagen.

The new EULAR recommendations were said to differ from the American College of Rheumatology (ACR) criteria, developed in 1986, in that they are aimed at clinical diagnosis rather than classification. They also are more generalizable because they are based on a global, evidence-based literature review and expert consensus across several countries.

A multidisciplinary panel made up of 17 OA experts from 12 European countries developed 10 key recommendations and tested their diagnostic accuracy on 2 study populations. They found that the correct diagnosis of knee OA could be made in 99% of patients with the presence of 3 symptoms—persistent knee pain, limited morning stiffness, and reduced function—and 3 examination findings—crepitation, restricted movement, and bony enlargement. The panel noted that the probability of a patient having knee OA with all features present increases to 99% from 19% when only persistent knee pain is evident.

The recommendations cite plain knee radiographs as the reference standard for diagnostic imaging, noting that MRI is more sensitive but less specific. A thorough physical examination for any patient who complains of knee pain also is recommended.

A revision of rheumatoid arthritis (RA) diagnostic criteria currently being undertaken by an ACR-EULAR joint task force was updated in a progress report at the EULAR meeting. The goals are to help clinicians determine which patients have RA (rather than OA or another condition) before the condition becomes chronic and irreversible joint damage sets in and identify patients who would benefit from disease-modifying antirheumatic drugs earlier in the disease process. The revision is based on the notion that the current criteria rely too much on features that reflect advanced disease (eg, joint erosion and subcutaneous nodules) and that more use of blood tests would improve diagnosis. The completed revision is expected to be released at the ACR's annual meeting in October.

A third set of recommendations discussed at the EULAR meeting is designed to guide clinicians in the management of cardiovascular disease (CVD) in patients with RA. The main recommendation is that clinicians consider patients with RA, ankylosing spondylitis (AS), or psoriatic arthritis (PsA) to be at high risk for CVD because of an increased prevalence of CVD risk factors in these patients and their increased inflammatory burden. Other recommendations include adequately controlling rheumatologic disease activity to lower a patient's CVD risk; conducting an annual CVD risk assessment following evidence-based EULAR guidelines for all patients with RA and, perhaps, patients with AS or PsA; and multiplying CVD risk score models by 1.5 when a patient with RA meets at least 2 of the criteria (disease duration of longer than 10 years, extra-articular manifestations, and positivity for rheumatoid factor or anticyclic citrullinated peptide antibodies).

For more information about these and other developments at the meeting, visit the EULAR Web site at Or, contact the organization at the European League Against Rheumatism, EULAR Secretariat, Seestrasse 240, CH 8802-Kilchberg, Switzerland; telephone: + 41 44 716 30 30; fax: + 41 44 716 30 39.

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