Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
Rheumatology, Bacs-Kiskun Megyei Korhaz, Kecskemet, Hungary.
RMD Open. 2021 Jan;7(1). doi: 10.1136/rmdopen-2020-001511.
To summarise the evidence on diagnostic issues in difficult-to-treat rheumatoid arthritis (D2T RA) informing the EULAR recommendations for the management of D2T RA.
A systematic literature review (SLR) was performed regarding the optimal confirmation of a diagnosis of rheumatoid arthritis (RA) and of mimicking diseases and the assessment of inflammatory disease activity. PubMed and Embase databases were searched up to December 2019. Relevant papers were selected and appraised.
Eighty-two papers were selected for detailed assessment. The identified evidence had several limitations: (1) no studies were found including D2T RA patients specifically, and only the minority of studies included RA patients in whom there was explicit doubt about the diagnosis of RA or presence of inflammatory activity; (2) mostly only correlations were reported, not directly useful to evaluate the accuracy of detecting inflammatory activity in clinical practice; (3) heterogeneous, and often suboptimal, reference standards were used and (4) (thus) only very few studies had a low risk of bias.To ascertain a diagnosis of RA or relevant mimicking disease, no diagnostic test with sufficient validity and accuracy was identified. To ascertain inflammatory activity in patients with RA in general and in those with obesity and fibromyalgia, ultrasonography (US) was studied most extensively and was found to be the most promising diagnostic test.
This SLR highlights the scarcity of high-quality studies regarding diagnostic issues in D2T RA. No diagnostic tests with sufficient validity and accuracy were found to confirm nor exclude the diagnosis of RA nor its mimicking diseases in D2T RA patients. Despite the lack of high-quality direct evidence, US may have an additional value to assess the presence of inflammatory activity in D2T RA patients, including those with concomitant obesity or fibromyalgia.
总结有关难治性类风湿关节炎（D2T RA）诊断问题的证据，为 EULAR 关于 D2T RA 管理的建议提供信息。
对类风湿关节炎（RA）诊断和类似疾病的最佳确认以及炎症性疾病活动评估的相关文献进行了系统评价（SLR）。检索了 PubMed 和 Embase 数据库，截至 2019 年 12 月。选择并评估了相关论文。
共选择了 82 篇论文进行详细评估。所确定的证据存在几个局限性：（1）未发现专门包括 D2T RA 患者的研究，只有少数研究包括 RA 患者，这些患者对 RA 诊断或炎症活动的存在存在明确的怀疑；（2）大多数仅报告了相关性，不能直接用于评估在临床实践中检测炎症活动的准确性；（3）使用了异质且通常不理想的参考标准；（4）因此，只有极少数研究具有低偏倚风险。为了确定 RA 或相关类似疾病的诊断，没有发现具有足够有效性和准确性的诊断测试。为了确定一般 RA 患者以及肥胖和纤维肌痛患者的炎症活动，超声检查（US）研究最为广泛，被认为是最有前途的诊断测试。
本 SLR 强调了关于 D2T RA 诊断问题的高质量研究的稀缺性。没有发现具有足够有效性和准确性的诊断测试来确认或排除 D2T RA 患者的 RA 或其类似疾病的诊断。尽管缺乏高质量的直接证据，但 US 可能具有额外的价值来评估 D2T RA 患者，包括那些同时患有肥胖症或纤维肌痛的患者的炎症活动。
