ACR Diagnostic Guidelines

Rheumatoid Arthritis

Osteoporosis

Sjogren’s Syndrome

Pain Management

ACR Clinical Classification Criteria for Osteoarthritis of the hip

Using history, physical examination and laboratory findings:
Flow 01

Using history, physical examination, laboratory and radiographic findings:
> Traditional format
Flow 02

> Classification tree
Flow 03

Reference: Altman, R, et al.: Arthritis Rheum 34:505, 1991

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ACR Clinical Classification Criteria for Osteoarthritis of the knee:

Using history and physical examination
Flow 4

Using history, physical examination and radiographic findings:
Flow 5

Using history, physical examination and laboratory findings:
Flow 6

Reference: Altman, R, et al.: Arthritis Rheum 29:1039, 1986.

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ACR Clinical Classification Criteria for Osteoarthritis of the hand

Clinical Classification Criteria for Osteoarthritis of the Hand

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ACR Guidelines for Medical Management of Osteoarthritis of the hip

Updated 2000
Steps should be followed sequentially, moving to the next step if the patients’ response proves inadequate.
image

Reference: American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Arthritis Rheum 43(9):1905-15, 2000.

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ACR Guidelines for Medical Management of Osteoarthritis of the knee

Updated 2000
Steps should be followed sequentially, moving to the next step if the patients’ response proves inadequate.
Medical Management of Osteoarthritis of the Knee

Reference: American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Arthritis Rheum 43(9):1905-15, 2000.

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ACR Clinical Classification Criteria for Rheumatoid Arthritis

Using history, physical examination, laboratory and radiographic findings:

> Traditional format Flow 10

> Classification tree
Flow 11

Reference: Arnett FC, et al.: Arthritis Rheum 31:315, 1988.

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ACR Clinical Classification Criteria for Juvenile Rheumatoid Arthritis

GENERAL CLASS
a. Persistent arthritis of at least six weeks duration in one or more joints
b. Exclusion of other causes of arthritis (see list of exclusions+)

onset subtypes-determined by manifestations during the first six months of disease although manifestations more closely resembling another subtype may appear later

Systemic onset JRA*
Flow 12

subtypes:
Polyarthritis
Oligoarthritis

*Typical fever and rash will be considered probable systemic onset JRA if not associated with arthritis. Before a definite diagnosis can be made, arthritis, as defined must be present.

Pauciarticular*
Flow 13

subtypes:
Antinuclear antibody (ANA) positive-chronic uveitis
Rheumatoid factor (RF) positive
Seronegative, B27 positive
Not otherwise classified

*Patients with systemic onset JRA are excluded from this onset subtype.

Polyarticular
Flow 14

subtypes:
RF positivity
Not otherwise classified

*Patients with systemic JRA onset are excluded from this subtype.

+EXCLUSIONS

  1. Other rheumatic diseases
    1. Rheumatic fever
    2. Systemic lupus erythematosus
    3. Ankylosing spondylitis
    4. Polymyositis or dermatomyositis
    5. Vasculitic syndromes
    6. Scleroderma
    7. Psoriatic arthritis
    8. Reiter’s syndrome
    9. Sjogren’s syndrome
    10. Mixed connective tissue disease
    11. Behcet’s syndrome
  2. Infectious arthritis
  3. Inflammatory bowel disease
  4. Neoplastic diseases including leukemia
  5. Nonrheumatic conditions of bones and joints
  6. Hematologic diseases
  7. Psychogenic arthralgia
  8. Miscellaneous
  9. Sarcoidosis
  10. Hypertrophic osteoarthropathy
  11. Villonodular synovitis
  12. Chronic active hepatitis
  13. Familial Mediterranean fever

Reference: JRA Criteria Subcommittee of the Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association Arthritis Rheum 20(Suppl)195, 1977

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ACR Classification Criteria for Determining Progression of Rheumatoid Arthritis

*These criteria describe either spontaneous remission or a state of drug-induced disease suppression.
Classification Criteria for Determining Progression of Rheumatoid Arthritis

Reference: Steinbrocker O, et.al.: JAMA 140:659, 1949.

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ACR Classification Criteria for Determinining Clinical Remission in Rheumatoid Arthritis

5 or more of the following present at least two consecutive months:

a. Morning stiffness < 15 minutes
b. No fatigue
c. No joint pain
d. No joint tenderness or pain on motion
e. No soft tissue swelling in joints or tendon sheaths
f. ESR (Westergren methold) < 30 mm/hour for a female or 20 mm/hour for a male

Exclusions: Clinical manifestations of active vasculitis, pericarditis, pleuritis or myositis, and unexplained recent weight loss or fever attributable to rheumatoid arthritis will prohibit a designation of complete clinical remission.

Reference: Pinals RS, et.al.: Arthritis Rheum 24:1308, 1981.

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ACR Classification Criteria of Functional Status in Rheumatoid Arthritis

Class I: Completely able to perform usual activities of daily living (self-care, vocational, and avocational)*
Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities
Class III: Able to perform usual self-care activities, but limited in vocational and avocational activities
Class IV: Limited ability to perform usual self-care, vocational, and avocational activities

 

*Self-care activities include dressing, feeding, bathing, grooming, and toileting. Avocational (recreational and/or leisure) and vocational (work, school, homemaking) activities are patient-desired and age- and sex-specific.

Reference: Hochberg MC, et.al.: Arthritis Rheum 35:498, 1992.

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ACR Guidelines for Medical Management of Rheumatoid Arthritis (updated April, 2002)

Medical management of Rheumatoid Arthritis

Reference: Arthritis & Rheum 46(2):328, 2002. Guidelines for the Management of Rheumatoid Arthritis. ACR Subcommittee.
©American College of Rheumatology. Reproduced with permission of Wiley Periodicals, Inc.

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ACR Definition of Improvement in RA trials

In the past, the outcome criteria used in clinical trials to determine the effectiveness of new agents has varied making the comparison between agents and between clinical trials difficult. Two well accepted composite measures of improvement have emerged-the Paulus Criteria and The American College of Rheumatology Criteria (ACR). ACR criteria is rapidly becoming the current gold standard.

Paulus Criteria*
image
*The level of improvement is set as a percentage improvement of each of these variables i.e. a Paulus 20 classification indicates a responder who has shown 20% improvement in 4 of the 6 parameters.

The American College of Rheumatology Criteria (ACR) Criteria
image
Improvement is denoted as either ACR 20, ACR 50 or ACR 70 reflecting either an improvement to the 20%, 50%, or 70% level in the parameters outlined. The ACR Success criteria (20, 50, 70) requires that the patient complete the trial and the patient meet ACR responder at the end of the trial.

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ACR Recommendations for Monitoring Hepatic Safety in Rheumatoid Arthritis (RA) Patients Receiving Methotrexate (MTX)

1. Baseline
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2. Monitor AST, ALT, albumin at every 4-8 weeks

3. Liver biopsy should be performed if:
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4. If results of liver biopsy are:
image

5. Discontinue MTX in patient with persistent liver test abnormalities, as defined in 3, who refuses liver biopsy.

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Osteoporosis Society of Canada Clinical Practice Guidelines for the Management of Osteoporosis

Comments by Dr. Michele Bellantoni

Diagnosis Recommendations
The Guidelines clearly recommend bone mineral density testing for individuals over age 50 years with at least one major risk factor or two or more minor risk factors. The Guidelines also clearly recommend that everyone over the age of 65 years should have a bone mineral density test. This statement is broader than the US Preventive Task Force Guidelines published in the Annals of Internal Medicine, Sept. 2003, that recommend universal testing only for women over age 65 years.

Risk Factors for Osteoporosis

 

Major risk factors Minor risk factors
Age >65 years Rheumatoid Arthritis
Vertebral compression fracture Past history of clinical hyperthyroidism
Fragility fracture after age 40 Chronic anticonvulsant therapy
Family history of osteoporotic fracture (especially maternal hip fracture Low dietary calcium intake (see nutritions section)
Systemic glucocorticoid therapy of >3 months duration Smoker
Malabsorption syndrome Excessive alcohol intake
Primary hyperparathyroidism Excessive caffeine intake (see nutrition section)
Propensity to fall Weight <57 kg
Osteopenia apparent on x-ray film Weight loss >10% of weight at age 25
Hypogonadism Chronic heparin therapy
Early menopause (before age 45)

These data in the table below provide physicians and patients with useful data on which to base clinical decisions for treatment.

Average 10-year Probability of an Osteoporotis Fracture*

Age (years) Overall average probability (%) BMD expressed as T-score
1 0 -1 -2 below
-2.5
Men
50 3.3 1.8 2.7 4.2 6.3 9.2
55 3.9 1.9 3.0 4.6 7.0 10.4
60 4.9 2.5 3.6 5.4 7.9 11.6
65 5.9 3.0 4.3 6.2 8.8 13.0
70 7.6 3.4 5.1 7.4 10.9 16.2
75 10.4 4.1 6.3 9.6 14.4 21.5
80 13.1 5.3 7.7 11.1 15.8 23.2
85 13.1 5.3 7.5 10.4 14.3 21.4
Women
50 6.0 2.4 3.8 5.9 9.2 13.9
55 7.8 2.6 4.1 6.7 10.7 16.8
60 10.6 3.2 5.1 8.2 13.0 20.5
65 14.3 4.0 6.3 10.0 15.6 24.9
70 18.9 4.3 7.1 11.5 18.3 29.8
75 22.9 4.2 7.0 11.8 19.4 32.6
80 26.5 4.6 7.7 12.7 20.5 34.4
85 27.0 4.5 7.4 12.0 19.1 33.1

*wrist, hip, proximal humerus, vertebra.
Kanis et al. Osteoporosis Int 12:989, 2001.

Dietary Recommendations
It is encouraging to find that the Canadian guidelines recommend Vitamin D daily intake of 800 IU for men and women ages > 50 years. The US RDA continues to be 400 IU, though the literature supports 800 IU for the older adults, though the minimum age for the higher recommendation has not been well established.

The Canadian Guidelines explicitly do not recommend supplementation with the following nutrients: magnesium, copper, zinc, phosphorus, manganese, iron, and essential fatty acids. The guidelines correctly state that that no evidence exists to recommend supplementation with these nutrients. Many people spend excessive amounts of money on these types of nutritional supplements. The Canadian Guidelines differ in the recommendation of daily calcium intake for men ages 50-65 years from the current US RDA for adult men (1500 mg vs. 1000mg). I am not aware of evidence to support this recommendation.

Recommended Daily Intake

CALCIUM
Prepubertal children (ages 4-8) 800 mg/day
Adolescents (ages 9-18) 1300 mg/day
Women (ages 19-50) 1000 mg/day
Women (ages over 50) 1500 mg/day
Pregnant and lactating women (ages > 18) 1000 mg/day
Men (ages 19-50) 1000 mg/day
Men (ages over 50) 1500 mg/day
VITAMIN D3
(Vitamin D2 shows less potency and more may be required to meet these recommendations)
Women (ages 19-50) 400 IU (10ug/day
Women (ages over 50) 800 IU (20ug/day
Men (ages 19-50) 400 IU (10ug/day
Men (ages over 50) 800 IU (20ug/day
ADDITIONAL NUTRIENTS
Adequate protein intake is important
Avoid excess caffeine (> 4 cups coffee/day)
Avoid excess dietary sodium (> 2100 mg/day or > 90 mmol/day) as it reduces BMD in adult men and women.
No evidence exists to recommend supplementation with the following nutrients for the prevention or treatment of osteoporosis: magnesium, copper, zinc, phosporus, manganese, iron, essential fatty acids

Treatment Recommendations
The Canadian Guidelines appropriately recommend oral bisphosphonates as first-line prevention and treatment of postmenopausal and glucocorticoid-induced osteoporosis, and in the treatment of men with osteoporosis. These Guidelines appropriately do not recommend oral bisphosphonate therapy for premenopausal women of child-bearing potential due to lack of evidence of safety. Additionally, the Guidelines appropriately recommend intranasal calcitonin as second-line treatment because of the lack of efficacy in the prevention of hip fractures in the large-scale clinical trials.

The Canadian Guidelines incorporate the results of the Womens Health Initiative Study in which no cardiovascular benefits of estrogen and progestin co-therapy were found to offset the risks of breast cancer and thromboembolic events of this therapy. The Guidelines also recommend estrogen as a second-line treatment, and caution about the risks of hormone replacement when used as a first-line preventive therapy. The Guidelines appropriately list the selective estrogen receptor modulator, raloxifene as first-line prevention and treatment of postmenopausal osteoporosis.

The Canadian Guidelines appropriately recommend against the use of Vitamin K and fluoride as treatments.

The Canadian Guidelines appropriately recommend parathyroid hormone therapy as first-line only for severe osteoporosis. The cost and potential side effects of the newly released preparation, hPTH (1-34), make this drug appropriate for use in extreme cases.

Optimal Treatment of Osteoporosis in Postmenopausal Women
flow diagram of treatment for osteoporosis in postmenopausal women
*mainly vertebral fracture. Only alendronate and risedronate and recently continuous estrogen-progesterone have been shown to decrease hip fracture risk.

Reference: JAMC 167(10 suppl), 2002

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ACR Guidelines for the Prevention and Treatment of Glucocorticoid Induced Osteoporosis

Initial Evaluation
Inital Eval 1
Initial Eval 2
Initial Eval 3

> Follow-up for abnormal laboratory findings

Abnormal Findings

> Approach to the patient starting long-term glucocorticoid treatment

Long Term Treatment

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Recommendations for the Preventions and Treatment of Glucocorticoid-Induced Osteoporosis **Updated 2001

The following updated recommendations are the result of work by the ACR Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis published in Arthritis Rheum 44(7), 2001.

> Patient beginning therapy with glucocorticoid (prednisone equivalent of > 5 md/day) with plans for treatment duration of > 3 months.

Flow Update

> Patient receiving long-term glucocorticoid therapy(prednisone equivalent of > 5md/day)

Flow Update 2

Reference: Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheum 44:1496-1503, 2001.

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EEC Criteria for Diagnosis of Sjögren’s Syndrome

FOUR OR MORE OF THE FOLLOWING CRITERIA MUST BE PRESENT
Criteria

Reference: Vitali C, Bomardieri S, Moutsopoulos HM. Preliminary criteria for the classification of Sjögren’s syndrome. Results of a prospective concerted action supported by the European Community. Arthritis Rheum 36, 1993.

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AGS Clinical Practice Guidelines for The Management of Chronic Pain in Older Persons

Key Recommendations
Key Recommendations

Reference: American Geriatrics Society Clinical Practice Guidelines: The Management of Chronic Pain in Older Persons. Geriatrics 53(Suppl 3:S6-7), 1998.

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Updated: July 31, 2012

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