American College Of Rheumatology Classification Criteria Research Articles

How Do We Classify Rheumatoid Arthritis in Established Disease — Can We Apply the 2010 American College of Rheumatology/European League Against Rheumatism Classification Criteria?

The creation of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis (RA; Figure 1)1 sought to address some of the criticisms of the previous ACR criteria set published in 1987 (Figure 2)2 — namely that they were insensitive, particularly early in the disease course, and that this led to the exclusion of many patients with early disease from clinical trials and research studies3. As a result, there was an absence of evidence regarding the efficacy of new treatments in this group of patients, who may have had the potential to benefit the most4,5. Thus, 1 aim of the 2010 criteria was to identify those patients with early RA with the key purpose of rapid disease-modifying antirheumatic drug (DMARD) initiation. However, the ability to classify patients as having RA is important at all phases of the disease, early and late. A case definition is required as an entry criterion not only to clinical trials, but also a consensus for inclusion in longterm observational studies and the whole spectrum of research in RA. Numerous studies have tested the validity of the new criteria since their publication against various standards6, but they have generally been applied in patients with relatively short duration of symptoms, ranging from < 3 months to < 2 years. Thus, the question remains, can we extend these classification criteria to patients with established disease? Figure 1. 2010 ACR/EULAR Classification criteria for RA1. ACR: American College of Rheumatology; EULAR: European League Against Rheumatism; RF: rheumatoid factor; ACPA: anticitrullinated protein antibodies; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; RA: rheumatoid arthritis. From Aletaha, et al. Ann Rheum Dis 2010;69:1580–8; with permission. Figure 2. 1987 ACR Classification criteria for RA2. ACR: American … Address correspondence to Professor D.P.M. Symmons, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, UK. E-mail: deborah.symmons{at}manchester.ac.uk

New classification criteria for systemic lupus erythematosus correlate with disease activity.

AimTo determine the prevalence of American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) classification criteria among systemic lupus erythematosus (SLE) patients; to determine disease activity and severity; and to investigate the correlation of classification criteria with disease activity, and of disease activity and damage index with disease duration.MethodsWe performed a cross-sectional study on 110 SLE patients from the Division of Rheumatology and Clinical Immunology, University Hospital Centre Rijeka, Croatia in the period from September to December 2013 and determined disease duration and the total number of ACR and SLICC classification criteria. Disease activity was assessed by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) index and organ damage by Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index.ResultsThe number of SLICC classification criteria met per patient was significantly higher than the number of ACR criteria (7 [IQR 6-8] vs 5 [IQR 4-6], P < 0.001). Moderate correlations were detected between the number of SLICC classification criteria and disease activity index, both in case of active (r = 0.48, P = 0.003) and inactive disease (r = 0.43, P < 0.001). We neither found a correlation between the number of ACR criteria and disease activity nor between disease activity and disease duration. However, there was a good correlation between SLICC/ACR damage index and disease duration (r = 0.63, P < 0.001).ConclusionNew SLICC classification criteria correlate with disease activity because they capture more manifestations also included in the SLEDAI index. Patients with longer disease duration had a larger damage index score.

OP0201 Outcome of Lupus Nephritis: Results from an International, Prospective, Inception Cohort Study

BackgroundThe outcome of lupus nephritis has evolved over the past decade due to improved immunosuppressive therapies and close attention to co-morbidities.ObjectivesTo study a large, prospective, multi-ethnic/racial, inception cohort of patients...

FRI0444 Comparison of ACR (1990) and Eular/Printo/Pres (2010) Classification Criteria in Adult IGA Vasculitis

BackgroundIn 2010 EULAR/PRINTO/PRES proposed new classification criteria for IgA vasculitis (IgAV).(1) In paediatric patient population these criteria have a higher diagnostic sensitivity than the older American College of Rheumatology (ACR)...

Diagnosis of Sjögren's Syndrome

Classification criteria provide a formalized approach to studying course and management of rheumatic disease, as well as a measure of improvement in care. Understanding the purposes of classification criteria sets and the differences between different classification criteria is crucial for understanding rheumatic disease and for the design and conduct of clinical and epidemiologic investigations. In this article, the similarities and differences between the American-European Consensus Group Criteria (AECG) and the newly proposed American College of Rheumatology (ACR) classification criteria for Sjögren's syndrome and the clinical implications of switching to the ACR classification criteria from the AECG are described.

2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative

ObjectiveThe 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis (SSc) lack sensitivity for early SSc and limited cutaneous SSc. The present work, by a joint committee of...

2013 Classification Criteria for Systemic Sclerosis: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative

ObjectiveThe 1980 American College of Rheumatology (ACR) classification criteria for systemic sclerosis (SSc) lack sensitivity for early SSc and limited cutaneous SSc. The present work, by a joint committee of the ACR and the European League Against Rheumatism (EULAR), was undertaken for the purpose of developing new classification criteria for SSc.MethodsUsing consensus methods, 23 candidate items were arranged in a multicriteria additive point system with a threshold to classify cases as SSc. The classification system was reduced by clustering items and simplifying weights. The system was tested by 1) determining specificity and sensitivity in SSc cases and controls with scleroderma‐like disorders, and 2) validating against the combined view of a group of experts on a set of cases with or without SSc.ResultsIt was determined that skin thickening of the fingers extending proximal to the metacarpophalangeal joints is sufficient for the patient to be classified as having SSc; if that is not present, 7 additive items apply, with varying weights for each: skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynaud's phenomenon, and SSc‐related autoantibodies. Sensitivity and specificity in the validation sample were, respectively, 0.91 and 0.92 for the new classification criteria and 0.75 and 0.72 for the 1980 ACR classification criteria. All selected cases were classified in accordance with consensus‐based expert opinion. All cases classified as SSc according to the 1980 ACR criteria were classified as SSc with the new criteria, and several additional cases were now considered to be SSc.ConclusionThe ACR/EULAR classification criteria for SSc performed better than the 1980 ACR criteria for SSc and should allow for more patients to be classified correctly as having the disease.

FRI0322 Diagnostic accuracy of new american college of rheumatology classification criteria for sjogren’s syndrome of 2012

BackgroundThe American-European Classification Criteria (AECC) for Sjogren’s syndrome (SS) of 2002 include the six items: I) symptoms of ocular and II) oral dryness, III) objective evidence of dry eyes (abnormal...

Early diagnosis of granulomatosis with polyangiitis: An introduction to the newly designed Iran criteria

BackgroundsIn the absence of practical diagnostic criteria for diagnosis of granulomatosis with polyangiitis (GPA), a new diagnostic criteria for GPA is proposed based on literature review for characteristic manifestations of GPA and expert opinion. The sensitivity of the new criteria, Iran criteria for GPA, is assessed in comparison with 1990 American College of Rheumatology (ACR) criteria for Wegener's granulomatosis (WG). MethodsEvaluation of three organs (ear, nose and throat (ENT); lung; kidney) and two laboratory findings (anti-neutrophil cytoplasmic antibody; biopsy), abbreviated mnemonically as ELKAB, is suggested in our criteria. A retrospective sensitivity analysis was performed based on medical records of 35 patients. Clinical diagnosis of GPA by a single rheumatologist was used as the gold standard. ResultsRecords of a total of 15 male and 20 female patients with a mean follow-up duration of 21.26 ± 4.13 months were considered. Mean age at diagnosis and mean disease duration were 32.37 ± 2.33 years and 19.06 ± 5.41 months, respectively. The sensitivity for Iran criteria for GPA and 1990 ACR classification criteria for WG were calculated as 100% and 80%, respectively. ConclusionsIran criteria for GPA is a highly sensitive instrument for detecting GPA patients in comparison with 1990 ACR classification criteria for WG.

Do the 2010 ACR/EULAR or ACR 1987 classification criteria predict erosive disease in early arthritis?

BackgroundThe new 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis (RA) aim at earlier diagnosis of RA compared to the 1987 ACR criteria.ObjectiveTo...

The incidence of rheumatoid arthritis in the UK: comparisons using the 2010 ACR/EULAR classification criteria and the 1987 ACR classification criteria. Results from the Norfolk Arthritis Register

ObjectivesThe development of new classification criteria for rheumatoid arthritis (RA) calls for a re-estimation of RA incidence rates. The objectives of this study were to estimate the age and sex-specific...

Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus

The Systemic Lupus International Collaborating Clinics (SLICC) group revised and validated the American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) classification criteria in order to improve clinical relevance, meet stringent methodology requirements, and incorporate new knowledge regarding the immunology of SLE. The classification criteria were derived from a set of 702 expert-rated patient scenarios. Recursive partitioning was used to derive an initial rule that was simplified and refined based on SLICC physician consensus. The SLICC group validated the classification criteria in a new validation sample of 690 new expert-rated patient scenarios. Seventeen criteria were identified. In the derivation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (49 versus 70; P = 0.0082) and had greater sensitivity (94% versus 86%; P < 0.0001) and equal specificity (92% versus 93%; P = 0.39). In the validation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (62 versus 74; P = 0.24) and had greater sensitivity (97% versus 83%; P < 0.0001) but lower specificity (84% versus 96%; P < 0.0001). The new SLICC classification criteria performed well in a large set of patient scenarios rated by experts. According to the SLICC rule for the classification of SLE, the patient must satisfy at least 4 criteria, including at least one clinical criterion and one immunologic criterion OR the patient must have biopsy-proven lupus nephritis in the presence of antinuclear antibodies or anti-double-stranded DNA antibodies.

Neuropsychiatric Lupus: The Prevalence and Autoantibody Associations Depend on the Definition: Results from the 1000 Faces of Lupus Cohort

The (ever) prevalence of neuropsychiatric systemic lupus erythematosus (NPSLE) can vary widely depending on the definition used. We determined the prevalence of NPSLE in 1000 Faces of Lupus, a large multicenter Canadian cohort. Adults enrolled at 10 sites who satisfied the American College of Rheumatology (ACR) classification for systemic lupus erythematosus (SLE) were included. NPSLE was defined as (i) NPSLE by ACR classification criteria (seizures or psychosis), (ii) ACR, SLEDAI (seizure, psychosis, organic brain syndrome, cranial nerve disorder, headache, and cerebrovascular accident (CVA)), SLAM (CVA, seizure, cortical dysfunction, and headache), and SLICC (cognitive impairment, psychosis, seizures, CVA, cranial or peripheral neuropathy, and transverse myelitis) with and (iii) without minor nonspecific NPSLE manifestations (including mild depression, mild cognitive impairment, and electromyogram-negative neuropathies), and (iv) by ACR and SLEDAI neuropsychiatric (NP) indexes alone. Factors associated with NPSLE were explored using regression models. Cohort size was 1253, with mean disease 12 ± 10 years, mean age 41 ± 16 years, and 86% female. Subgroup size was dependent on the specific definition of NPSLE. Prevalence of NPSLE was 6.4% in group (i), n = 1253 (n = 80); 38.6% in group (ii), n = 681(n = 263); 28.7% in group (iii), n = 586 (n = 168); and 10.2% in group (iv), n = 1125 (n = 115). In univariate analysis, Aboriginals had a nearly 2-fold increase in frequency of NPSLE in all groups. Education level and income were not associated with NPSLE (P = 0.32 and 0.03, respectively). As well, number of ACR criteria, SLAM, age at diagnosis, disease duration, and gender were not associated with NPSLE. Anti-Ro was significantly associated in groups (i) and (iv) and antiphospholipid antibodies (aPL) were increased in groups (i), (ii), and (iii); however, this lost significance when thromboembolic events were excluded from SLICC, SLEDAI, and SLAM indexes. In group (iv), absence of anti-Sm was significant. In multivariate analysis, anti-Ro and aPL (i) and anti-Ro+ and lack of anti-Sm (iv) were significant. NPSLE was not increased in those with +anti-DNA, La, or ribonucleoprotein (RNP), lupus anticoagulant (LAC), or anticardiolipin (aCL) antibody. The prevalence and factors associated with NPSLE varied depending on the definition used, was highest in Aboriginals, and may be higher if +anti-Ro or aPL are present. SLAM and SLICC include mild subjective disease manifestations, which contributed to a 10% higher prevalence of NPSLE compared to a more strict definition. NPSLE may be less in this database than other publications as its overall prevalence may be decreasing, or because of selection bias inherent to those who enter an observational cohort. NPSLE was associated with aPL and often anti-Ro and varied by ethnicity.

Validity of simplified disease activity index using CRP titer in comparison to disease activity score-28 joints in Iraqi patients with active Rheumatoid arthritis

Objective: Various factors are known to determine the disease activity in patients with rheumatoid arthritis (RA). The ‘simplified disease activity’ index (SDAI) is new tool of measurement of disease activity. The present study was designed to assess validity of SDAI using C-reactive protein (CRP) titer in comparison to ‘disease activity score in 28 joints’ (DAS28) in Iraqi patients with active RA. Methods: Sixty nine Iraqi RA patients were included in this study. All patients were active and fulfilled the ACR (American College of Rheumatology) classification criteria. Full history was taken and complete clinical examination was done for all patients. Patients\' age, sex, number of swollen joints, visual analogue scale (VAS), and evaluators’ global assessment (EGA) were documented. Laboratory analysis included erythrocyte sedimentation rate (ESR), CRP, SDAI and DAS28 were measured to assess disease activity. Results: The results revealed direct significant correlation between SDAI and DAS28 (r = 0.903, p < 0.001), and reported a good agreement between SDAI and DAS28 (κ = 0.777, p < 0.001). SDAI was found as a valid measure for disease activity using CRP as a screening test compared to DAS28 (AUC = 0.983, p < 0.001). Conclusion: SDAI is a valid and sensitive measure for assessment of rheumatoid arthritis disease activity that is comparable with the DAS28 using semi quantitative method to estimate CRP.

Systematic review and network meta-analysis of combination and monotherapy treatments in disease-modifying antirheumatic drug-experienced patients with rheumatoid arthritis: analysis of American College of Rheumatology criteria scores 20, 50, and 70

BackgroundBiologic disease-modifying antirheumatic drugs (bDMARDs) extend the treatment choices for rheumatoid arthritis patients with suboptimal response or intolerance to conventional DMARDs. The objective of this systematic review and meta-analysis was to compare the relative efficacy of EU-licensed bDMARD combination therapy or monotherapy for patients intolerant of or contraindicated to continued methotrexate.MethodsComprehensive, structured literature searches were conducted in Medline, Embase, and the Cochrane Library, as well as hand-searching of conference proceedings and reference lists. Phase II or III randomized controlled trials reporting American College of Rheumatology (ACR) criteria scores of 20, 50, and 70 between 12 and 30 weeks’ follow-up and enrolling adult patients meeting ACR classification criteria for rheumatoid arthritis previously treated with and with an inadequate response to conventional DMARDs were eligible. To estimate the relative efficacy of treatments whilst preserving the randomized comparisons within each trial, a Bayesian network meta-analysis was conducted in WinBUGS using fixed and random-effects, logit-link models fitted to the binomial ACR 20/50/70 trial data.ResultsThe systematic review identified 10,625 citations, and after a review of 2450 full-text papers, there were 29 and 14 eligible studies for the combination and monotherapy meta-analyses, respectively. In the combination analysis, all licensed bDMARD combinations had significantly higher odds of ACR 20/50/70 compared to DMARDs alone, except for the rituximab comparison, which did not reach significance for the ACR 70 outcome (based on the 95% credible interval). The etanercept combination was significantly better than the tumor necrosis factor-α inhibitors adalimumab and infliximab in improving ACR 20/50/70 outcomes, with no significant differences between the etanercept combination and certolizumab pegol or tocilizumab. Licensed-dose etanercept, adalimumab, and tocilizumab monotherapy were significantly better than placebo in improving ACR 20/50/70 outcomes. Sensitivity analysis indicated that including studies outside the target population could affect the results.ConclusionLicensed bDMARDs are efficacious in patients with an inadequate response to conventional therapy, but tumor necrosis factor-α inhibitor combination therapies are not equally effective.

The American College of Rheumatology/European League Against Rheumatism criteria for the classification of rheumatoid arthritis: A game changer

Over the last several years the two pre-eminent professional societies representing rheumatology, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR), have been discussing increasing their collaboration in areas of interest to rheumatologists worldwide. These discussions resulted in a letter of agreement in 2008 on the framework whereby the two organisations would work together to develop disease classification criteria as well as recommendations for conducting of clinical trials. To enhance communication between the two organisations, ACR representatives now sit on the EULAR Standing Committee for Clinical Affairs and the EULAR Standing Committee of Epidemiology, and EULAR representatives now sit on the ACR Criteria Subcommittee and Quality of Care Committee. The first result of this effort was the joint publication, in Annals of the Rheumatic Diseases and Arthritis Care & Research , of the recommendations on reporting disease activity in clinical trials of patients with rheumatoid arthritis (RA).1 2 This document was important in that it delineated the minimal standards necessary for clinical trials evaluating new therapeutics in RA. Several collaborative projects are under way on RA, and also on gout, scleroderma, myositis and vasculitis. The positive aspects of developing a consensus between the dominant voices in world of rheumatology are self-evident. The recent initiative to revise the ACR classification criteria for RA3 is the most significant cooperation so far. For the past 2 years rheumatologists on both sides of the Atlantic have been working on this project, and the fruits of their work are …

The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity

To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms. We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale. Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI > or =7 AND SS > or =5) OR (WPI 3-6 AND SS > or =9). This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability.

Discriminative Value of Tender Points in Fibromyalgia Syndrome

The aim of this study is to assess the discriminative value of all tender points, alone and in combination, that are designated as criteria for fibromyalgia diagnosis by the American College of Rheumatology (ACR), by investigating the appropriate pressure magnitude that should be applied during tenderness examination. Cross-sectional. This study was performed on 66 patients with fibromyalgia diagnosed according to ACR classification criteria and 50 control subjects. The outpatient rheumatology clinic of a PM&R department of a university hospital. Intervention. Pressure pain threshold values were measured by a dolorimeter on nine specific point pairs in both groups and a cutoff value for discriminating positivity and negativity was calculated for each. Then the most valuable tender point pairs were assessed for discrimination of fibromyalgia syndrome using ACR criteria set as a reference standard. All tender points with determined pressure cutoff values were found out to significantly discriminate fibromyalgia syndrome and their area under curve values ranged from 0.779 to 0.934. Univariate logistic regression analysis revealed that lateral epicondyle and supraspinatus point pairs had the most powerful discriminative ability (odds ratio = 113.6 and 45.0, respectively). Multiple logistic regression analysis with backward stepwise method showed that lateral epicondyle and second rib point pairs were most discriminative with sensitivity and specificity rates of 87.9-94.0% and 77.3-84.0%, respectively. Fibromyalgia syndrome can have potential to be recognized simply by pressing fewer tender point areas but with various pressure cutoff levels identified for each tender point areas.

Gender bias in diagnosing fibromyalgia

Both patient- and physician-centered characteristics may influence disease classification c fibromyalgia (FM). This study assessed the diagnostic criteria for FM and how rheumatologists use these criter in clinical practice. Practicing rheumatologists were surveyed. Participants were asked to read a brief case description of a patient with FM and then to select those criteria most important to them for confirming tt diagnosis. Case studies of either male or female patients were randomly assigned. Data were analyzed using a random forests classification analysis to abstract the strongest variables for distinguishing disease classification--in this assessment, stratified by gender of the case study. A total of 61 surveys were analyzed. Four rheumatologists (6.6%) chose the 2 (and only the 2 criteria for FM classification (tender points and widespread pain) proposed by the American College of Rheumatology (ACR). The candidate diagnostic criteria discriminating between rheumatologists (when stratified by gender of the case study) consisted of (1) tender points, (2) normal erythrocyte sedimentatio rate, (3) normal thyroid tests, (4) fatigue, and (5) poor quality of sleep. Of these, the criterion of tender points was chosen by rheumatologists statistically more frequently for male patients (P = 0.047). This study provides insight into the diagnostic thought processes of rheumatologists. minority of practitioners relied solely on the published ACR classification criteria for the diagnosis of FM. We also report gender bias with regard to disease classification, because rheumatologists were more likely to require a physical finding to support a diagnostic conclusion in male patients.

Significance of anti-CCP antibodies in modification of 1987 ACR classification criteria in diagnosis of rheumatoid arthritis

To examine the incorporation of anti-CCP antibodies into the American College of Rheumatology (ACR) classification criteria for rheumatoid arthritis (RA) and to evaluate the advantages of the revised anti-CCP criteria in diagnosing Chinese patients. Patients who suffered from arthritic problems during the recent 2 years were selected from the Department of Rheumatology and Immunology of Peking University People's Hospital. The patients were divided into RA group and non-RA group according to the clinical diagnosis by experienced rheumatologists. The ACR criteria were revised in three ways: (1) replacement of rheumatoid nodules and erosions as criteria with anti-CCP antibodies (RA-6 criteria); (2) replacement of rheumatoid nodules with anti-CCP antibodies as a criterion (RA-7 criteria); (3) addition of anti-CCP antibodies (RA-8 criteria). The diagnostic value of ACR criteria and anti-CCP revised criteria (RA-6, RA-7, and RA-8) were evaluated by comparing the sensitivity and specificity of all criteria, in all subjects and in subjects with arthritis symptoms within 2 years. There were 604 patients included in the study totally, among whom 312 patients were diagnosed as RA and 292 were diagnosed as other rheumatic diseases by rheumatologists. For all the RA patients, the sensitivity and specificity of anti-CCP antibodies were 76.2% and 96%, respectively. Its specificity was much higher than RF (85.2%). For the patients with a disease duration less than two years, the sensitivities were 82.0%, 91.0%, 87.0%, and 87.0%, while the specificities were 95.6%, 83.9%, 95.6%, and 95.6%, respectively, according to 1987 ACR criteria, RA-6, RA-7, and RA-8 criteria. Among all the RA patients, the corresponding sensitivities were 92.3%, 96.8%, 94.6%, and 94.6%, and the specificities were 92.8%, 83.6%, 92.8%, and 92.8%, respectively. The 1987 ACR criteria have high sensitivity and specificity in established RA, but are less sensitive in early RA. The RA-6 criteria improve the sensitivity by reducing its specificity. The RA-7 criteria with replacement of rheumatoid nodules by anti-CCP antibodies increase the sensitivity without losing specificity, which may serve as new classification criteria in routine clinical practice, especially in early RA patients.