To the Editor:

Undoubtedly, rheumatoid arthritis (RA) is a complex heterogeneous disorder that has limited phenotypes and probably several genotypic variants, and there is a paucity of markers by which to characterize genotypic variants or to differentiate among diseases with similar clinical presentation. In India, with its high prevalence of various types of infections, this problem is well recognized, and, in a large number of patients with rheumatoid factor–negative inflammatory arthritis, an exact diagnosis is often not made (1, 2). In recent years, we have continued to encounter an unprecedented frequency of chronic arthritis following the Chikungunya epidemic of 2006 (3), and several of these cases are likely to satisfy the clinical and historical components of the new classification criteria reported by Aletaha et al (4).

The new RA criteria are a bold step toward capturing early disease, but a step back from identifying homogeneous subsets. I presume that a 68-joint count would be required in order to assess whether the criteria are met. Additionally, a medical history of single-joint synovitis, as stated in the Discussion section of Aletaha and colleagues' report, is likely to be a questionable basis for an RA diagnosis if the synovitis was not documented by a rheumatologist. In addition, synovitis documented by medical history may be substituted for a diagnosis of synovitis on current examination. If this is sufficient, it would be extremely important, and perhaps should have been explicitly stated in Table 3 of the publication. Inclusion of metatarsophalangeal joints in the criteria is indeed welcome, because feet were neglected in the previous criteria (5).

In the validation of the final criteria set (4), the correlation between cases' mean derived probabibility scores and the proportion of expert panel members indicating their willingness to initiate methotrexate (MTX) or refer for a new biologic agent was found to be strong. I presume that the experts were stating their opinion without referring to radiography and imaging results. Therefore, the current criteria may promote early use of disease-modifying antirheumatic drugs, particularly MTX, which is a laudable objective. I do believe, however, at least in our setting, that some subjects with an infectious or a relatively benign postinfectious arthritis would easily meet the new classification criteria and may be inappropriately treated with immunosuppressive agents. Beyond satisfying the critical score of 6 from the criteria, the patients would need followup to monitor the progressive nature of the disease, and, in some patients, such as those with undifferentiated arthritis, to further verify a diagnosis of RA.

Though a large part of the field of rheumatology has participated to create and validate the current criteria, a larger part of the field still waits to evaluate their usefulness. The criteria represent a welcome change, but they will need to be validated in socioeconomically challenging settings, such as ours. We intend to utilize the new criteria in our field work, as part of a current ongoing multiregional population survey (2). However when all is said and done, the new criteria represent a scientific step forward.

  • 1
    Chopra A, Abdel-Nasser A. Epidemiology of rheumatic musculoskeletal disorders in the developing world. Best Pract Res Clin Rheumatol 2008; 22: 583604.
  • 2
    Joshi VL, Chopra A. Is there an urban rural divide? Population surveys of rheumatic musculoskeletal disorders in the Pune region of India using the COPCORD Bhigwan Model. J Rheumatol 2009; 36: 61422.
  • 3
    Chopra A, Anuradha V, Lagoo-Joshi V, Kunjir V, Salvi S, Saluja M. Chikungunya virus aches and pains: an emerging challenge [concise communication]. Arthritis Rheum 2008; 58: 29212.
  • 4
    Aletaha D, Neogi T, Silman A, Funovits J, Felson DT, Bingham CO III, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010; 62: 256981.
  • 5
    Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 31524.

Arvind Chopra MD, DNB*, * Center for Rheumatic Diseases, Pune, India.