Patients with rheumatoid arthritis in clinical care

Taken together, our current clinical armamentarium to follow the course of RA offers several disease activity measures. Evaluation of radiographic destruction, but also of anatomical changes such as malalignment,77 can serve as outcome measure, because these changes best reflect the damage related to the pathological process in and around the joints; whether radiological changes can be reversible, is still a matter of debate. 78 Assessment of function reflects the combination of disease activity and damage. Questionnaires or other instruments which only determine functional improvement due to irreversible damage are not (yet) available. However, their development could lead to interesting, new clinical insights. Likewise, basic science has not yet provided us with tests that reflect the destructive process reliably. Measuring disease activity by surrogate measures such as the acute phase proteins does not reflect destruction at a single point in time. In conclusion, assessment of disease activity, damage, and functional capacity are equally important also in clinical practice; RA, if insufficiently controlled, may be a highly destructive disease. Achieving low disease activity, ideally a remission-like state, is pivotal to improving prognosis. 79 Current treatments and early institution of DMARDs allow this aim to be accomplished in many patients. However, decisions to switch (or to maintain) treatment require recording of the patients' clinical status, and in many healthcare systems the use of costly treatments, as increasingly employed, requires justification which, again, can only come from recorded data. 18 Rather than guessing disease activity and quality of life, providing evidence will validate decisions and improve quality of care. A combination of a more physician centred activity score, such as the SDAI or similar, with a patient centred functional measure, such as the HAQ or similar, in conjunction with an occasional evaluation of the radiographic situation, will give all necessary information for the longitudinal observation of patients' disease state in clinical practice. The tools are available and so relatively easy to use.