European Spondylarthropathy Study Group Research Articles

Classification criteria versus physician's opinion for considering a patient with inflammatory back pain as suffering from spondyloarthritis

ObjectiveTo assess agreement among methods for classifying patients with inflammatory back pain (IBP) after a 2-year follow-up. MethodsPatients with IBP in the French nationwide, longitudinal, prospective cohort DESIR were classified after 2years based on imaging findings, rheumatologist's confidence in a diagnosis of spondyloarthritis, three classification criteria sets (axial Assessment of Spondyloarthritis international Society [ASAS], European Spondylarthropathy Study Group [ESSG], and Amor) and treatment (TNFα antagonists). Agreement among these methods was assessed by computing the percentage of concordant classifications and Cohen's kappa coefficient. Using logistic regression, we identified the items most strongly associated with rheumatologist's confidence. ResultsAgreement among criteria sets was poor (kappa<0.6), even in the group with inflammation by magnetic resonance imaging. Of 708 patients, 541 had all available data including rheumatologist's confidence after 2years, which was 0/10 for 31 (5.7%) patients, 1/10 to 7/10 for 158 (29.2%) patients, 8/10 or 9/10 for 167 (30.9%) patients, and 10/10 for 185 (34.2%) patients. TNFα antagonists were used in 156/356 (43.8%) patients in the two highest confidence groups versus 53/188 (28.2%) patients in the two lowest confidence groups. Factors independently associated with confidence ≥8/10 were fulfilment of ASAS, ESSG, and Amor criteria. ConclusionConfidence of rheumatologists in the diagnosis of spondyloarthritis in patients with recent-onset IBP shows limited agreement with classification criteria. The best way to currently classify spondyloarthritis should be the association of both at least one classification criteria and a diagnosis of spondyloarthritis according to the rheumatologist.

Clinical and Imaging Signs of Spondyloarthritis in First-Degree Relatives of HLA-B27-Positive Ankylosing Spondylitis Patients: The Pre-Spondyloarthritis (Pre-SpA) Cohort Study.

To investigate whether seemingly healthy first-degree relatives of patients with ankylosing spondylitis (AS) have clinical, laboratory, or imaging features of spondyloarthritis (SpA). First-degree relatives (ages 18-40 years) of HLA-B27-positive AS patients were included in the pre-spondyloarthritis (Pre-SpA) cohort, a prospective inception cohort study. Clinical, biologic, and imaging features were recorded. First-degree relatives were classified according to several sets of SpA classification criteria. We report baseline features of 51 first-degree relatives included in this study. Twenty-nine (57%) had back pain, 2 (4%) had psoriasis, 1 (2%) had inflammatory bowel disease, and 1 (2%) had uveitis. Three (6%) had low-grade sacroiliitis, 1 (2%) had cervical syndesmophytes on radiography, and 10 (20%) had bone marrow edema on magnetic resonance imaging of the sacroiliiac joints. Seventeen of 51 first-degree relatives (33%) fulfilled SpA classification criteria: 7 (14%) fulfilled both Assessment of SpondyloArthritis international Society (ASAS) axial SpA and European Spondylarthropathy Study Group (ESSG) classification criteria, 6 (12%) fulfilled only ASAS axial SpA classification criteria, and 4 (8%) fulfilled only ESSG classification criteria; 3 (6%) also fulfilled the Amor criteria. None fulfilled other SpA classification criteria. First-degree relatives fulfilling the ASAS axial SpA and/or ESSG classification criteria had more frequent inflammatory back pain, had a higher level of disease activity, and had more psoriasis. No differences were found in parameters of inflammation, peripheral and extraarticular disease other than psoriasis, and HLA-B27 positivity between those who did and those who did not fulfill the ASAS axial SpA and/or ESSG classification criteria. Four first-degree relatives (12%) who did not fulfill the ASAS axial SpA and/or ESSG classification criteria had imaging abnormalities suggestive of SpA. A substantial proportion of seemingly healthy first-degree relatives of HLA-B27-positive AS patients have clinical and/or imaging abnormalities suggestive of SpA. Thirty-three percent could be classified as having SpA. Further follow-up will show which first-degree relatives will develop clinically manifest SpA.

Relationship of Psoriatic Arthritis to Other Spondyloarthritides.

In the early 1970s, Moll and co-workers formulated the unified concept of spondyloarthritides, a group of conditions sharing similar clinical features. Subsequently, criteria for their classification have been proposed by Amor and coworkers, the European Spondylarthropathy Study Group, and the Assessment in SpondyloArthritis international Society. Opinion, however, is divided between those who believe that the different entities of the complex represent the variable expression of the same disease ("lumpers") and those who think that these should be considered separately but under the same umbrella ("splitters"). Several sets of criteria have been proposed for psoriatic arthritis (PsA), the most recent being the ClASsification for Psoriatic Arthritis (CASPAR) criteria. According to some authors, there are persuasive arguments to support the view of PsA as a distinct entity.

Achilles tendinitis in systemic lupus erythematosus: search for an associated inflammatory disease.

Except for traumatic and iatrogenic causes, Achilles tendinitis (AT) is mostly encountered in the context of inflammatory rheumatic diseases. This study aimed to describe AT in systemic lupus erythematosus (SLE). Among 158 SLE patients who fulfilled the SLE criteria of the ACR classification followed between 1980 and 2013, we selected those who experienced at least one episode of AT not caused by traumatic or toxicity factors. Eight patients (one male, seven females), median age 52 years (range: 35-68), presented with 11 episodes of AT within an average of 10.5 (0-21) years after SLE diagnosis. Clinical presentation of SLE was mainly cutaneous (eight of eight), and articular (seven of eight). Axial symptoms were reported in six patients, two of whom had HLA-B27-positive status, and fulfilled the Amor and European Spondylarthropathy Study Group criteria. Resolution of AT was good with nonsteroidal anti-inflammatory topical or systemic drug therapies, which kept SLE quiescent and avoided any increase of specific treatment. Although the association is rare, when AT occurs in SLE patients, physicians should look for associated spondylarthritis.

Increase in Bone Density in Patients with Spondyloarthritis During Anti-Tumor Necrosis Factor Therapy: 6-year Followup Study

To assess the effects on bone mineral density (BMD) of prolonged anti-tumor necrosis factor (anti-TNF) therapy in patients with spondyloarthritis (SpA); to compare the BMD changes to those observed in SpA patients not treated with anti-TNF; and to identify the predictors of these changes. Fifty-nine patients with SpA according to the European Spondylarthropathy Study Group criteria who were treated with anti-TNF therapy for at least 4 years were included. Thirty-four patients with SpA from an international longitudinal observational study (OASIS cohort) were used as a control group. Lumbar spine and hip BMD were measured by dual-energy x-ray absorptiometry at baseline, after 1 year, and after at least 4 years. Over an average 6.5 years' followup, the increase in BMD was 11.8% (± 12.8%) at the lumbar spine (p < 0.0001) and 3.6% (± 9.3%) at the great trochanter (p = 0.0001) in patients treated with anti-TNF. At the lumbar spine, the increase was similar in patients with and those without syndesmophytes. BMD changes were significantly higher in the anti-TNF group than in the control group at lumbar spine (p < 0.0001), at femoral neck (p = 0.002), and at trochanter (p = 0.011), but not at total hip (p = 0.062). Multivariate analysis showed that the predictors of lumbar spine BMD changes in the total population were the use of anti-TNF (p < 0.0001) and, in the anti-TNF therapy group, the 1-year lumbar spine BMD change (p = 0.007). This study shows that prolonged anti-TNF therapy increases lumbar spine and trochanter BMD. This effect should be taken into account before introducing antiosteoporotic treatment in these patients.

SAT0169 Frequency of Spondyloarthritis in Italian Patients with BehÇEt’S Disease

BackgroundTill now the debate on the relationship between Behçet’s disease (BD) and spondyloarthritis (SpA) has been limited to whether the frequency of sacroiliitis and ankylosing spondylitis (AS) is greater or...

AB0569 Association between periodontal condition with disease duration and activity in colombian patients with spondyloarthritis

BackgroundIt has been suggested that rheumatic diseases may have additional underlying factors in common with chronic periodontitis. Spondyloarthritis (SpA) is associated with other inflammatory diseases such as psoriasis and uveitis;...

Incidence of Spondyloarthropathy in Patients with Ulcerative Colitis: A Population-based Study

Spondyloarthritis (SpA) is an important extraintestinal manifestation of inflammatory bowel disease (IBD). We assessed the cumulative incidence and clinical spectrum of SpA in a population-based cohort of patients with ulcerative colitis (UC). The medical records of a population-based cohort of residents of Olmsted County, Minnesota, USA, diagnosed with UC from 1970 through 2004 were reviewed. Patients were followed longitudinally until moving from Olmsted County, death, or June 30, 2011. We used the European Spondylarthropathy Study Group, Assessment of Spondyloarthritis International Society (ASAS) criteria, and modified New York criteria to identify patients with SpA. The cohort included 365 patients with UC, of whom 41.9% were women. The median age at diagnosis of UC was 38.6 years (range 1.2-91.4). Forty patients developed SpA based on the ASAS criteria. The cumulative incidence of a diagnosis of SpA after an established diagnosis of UC was 4.8% at 10 years (95% CI 95% CI 2.2%-7.3%), 13.7% at 20 years (95% CI 9.0%-18.1%), and 22.1% at 30 years (95% CI 4.3%-29.1%). The cumulative incidence of all forms of SpA increased to about 22% by 30 years from UC diagnosis. This value is slightly greater than what we previously described in a population-based cohort of Crohn disease diagnosed in Olmsted County over the same time period. SpA and its features are associated with UC, and heightened awareness on the part of clinicians is needed for diagnosing and managing them.

Anti-TNF agents for the treatment of active non-radiographic axial spondyloarthritis

The spondyloarthritis (SpA) complex includes ankylosing spondylitis (AS), reactive arthritis, psoriatic arthritis, arthritis related to inflammatory bowel disease and forms that do not meet established criteria for these definite categories which are designated as undifferentiated SpA. In the early 1990s, two sets of classification criteria were suggested with the purpose to cover the whole clinical spectrum of SpA: the Amor criteria and the European Spondylarthropathy Study Group (ESSG) criteria...

Incidence of Spondyloarthropathy in Patients with Crohn’s Disease: A Population-based Study

Spondyloarthritis (SpA) is an extraintestinal manifestation of inflammatory bowel disease with significant clinical effects, although the frequency is uncertain. We assessed the cumulative incidence and clinical spectrum of SpA in patients with Crohn's disease (CD) in a population-based cohort. The medical records of a population-based cohort of Olmsted County, Minnesota, residents diagnosed with CD between 1970 and 2004 were reviewed. Patients were followed longitudinally until migration, death, or December 31, 2010. We used the European Spondylarthropathy Study Group, Assessment of Spondyloarthritis international Society (ASAS) criteria and modified New York criteria to identify patients with SpA. The Kaplan-Meier method was used to estimate the cumulative incidence of SpA following diagnosis of CD. The cohort included 311 patients with CD (49.8% females; median age 29.9 yrs, range 8-89). Thirty-two patients developed SpA based on ASAS criteria. The cumulative incidence of SpA after CD diagnosis was 6.7% (95% CI 2.5%-6.7%) at 10 years, 13.9% (95% CI 8.7%-18.8%) at 20 years, and 18.6% (95% CI 11.0%-25.5%) at 30 years. The 10-year cumulative incidence of ankylosing spondylitis was 0, while both the 20-year and 30-year cumulative incidences were 0.5% (95% CI 0-1.6%). We have for the first time defined the actual cumulative incidence of SpA in CD using complete medical record information in a population-based cohort. The cumulative incidence of all forms of SpA increased to approximately 19% by 30 years from diagnosis of CD. Our results emphasize the importance of maintaining a high level of suspicion for SpA when following patients with CD.

The prevalence of inflammatory back pain: population-based estimates from the US National Health and Nutrition Examination Survey, 2009–10

ObjectiveTo estimate the current US inflammatory back pain (IBP) prevalence using four published case definitions.MethodsAnalysis of an IBP data collection instrument specifically designed for the 2009–10 National Health and Nutrition...

Prevalence and factors associated with uveitis in spondylarthritis patients in France: Results from an observational survey

To accurately estimate the prevalence of and the factors associated with uveitis in spondylarthritis (SpA) patients in France. In an observational survey of SpA patients (diagnosis confirmed by the European Spondylarthropathy Study Group and/or Amor's criteria) consulting their rheumatologist for routine followup, we collected information regarding present/past history of uveitis, as well as detailed characteristics of the disease. Factors independently associated with uveitis were determined. From September 2008 to January 2009, 202 rheumatologists participated in the survey and recruited 902 patients (61% men) with a mean ± SD age of 45.3 ± 13.4 years and a mean ± SD disease duration of 10.4 ± 9.6 years. The SpA diagnoses were ankylosing spondylitis (71%), psoriatic arthritis (18%), or other SpA (11%). The HLA-B27 positivity rate was 76%. Uveitis prevalence was 32.2% (95% confidence interval [95% CI] 29.1-35.3%) since psoriasis and inflammatory bowel disease were 22.3% (95% CI 19.5-25.0%) and 8.6% (95% CI 6.7-10.5%), respectively. Recurrence of uveitis occurred in 52.3% and complications occurred in 11.7% of patients. Factors independently associated with uveitis were HLA-B27 positivity (adjusted odds ratio [OR(adj) ] 2.97 [95% CI 1.83-4.81], P < 0.0001) and disease duration (OR(adj) 1.28 [95% CI 1.16-1.41], P < 0.0001 for ≥10 years). Results indicate that uveitis is the most common extraarticular feature of SpA, occurring preferentially in HLA-B27-positive patients over the entire course of the disease.

Prevalence of axial spondylarthritis in the United States: Estimates from a cross‐sectional survey

The US national prevalence of spondylarthritis (SpA) was estimated for 2 published sets of classification criteria: the Amor criteria and the European Spondylarthropathy Study Group (ESSG) criteria. These 2 SpA criteria sets have been the most widely utilized in previous population-based studies of SpA. The US SpA prevalence estimates were based on a representative sample of 5,013 US adults ages 20-69 years who were examined in the US National Health and Nutrition Examination Survey (NHANES) 2009-2010. The overall age-adjusted prevalence of definite and probable SpA by the Amor criteria was 0.9% (95% confidence interval [95% CI] 0.7-1.1%), corresponding to an estimated 1.7 million persons (95% CI 1.4-2.1 million persons). The age-adjusted prevalence of SpA by the ESSG criteria was 1.4% (95% CI 1.0-1.9%), corresponding to an estimated 2.7 million persons (95% CI 1.9-3.7 million persons). There were no statistically significant sex differences in SpA prevalence. The SpA prevalence among non-Hispanic white persons was 1.0% (95% CI 0.7-1.5%) by the Amor criteria and 1.5% (95% CI 1.0-2.3%) by the ESSG criteria. SpA prevalence could not be reliably estimated in other race/ethnicity subgroups due to sample size imitations. The SpA prevalence estimates are in the range of SpA prevalence estimates reported elsewhere in population-based surveys and it is likely that SpA may affect up to 1% of US adults, a prevalence similar to that reported for rheumatoid arthritis. The current US SpA prevalence estimates may be lower than the true value because the NHANES 2009-2010 data collection did not capture a complete set of the elements specified in the 2 SpA criteria sets.

Late-Onset Spondyloarthritis: Subset That Should Not Be Forgotten

The spondyloarthritis (SpA) complex embraces ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), arthritis related to inflammatory bowel disease (IBD), and forms that do not fulfil established criteria, which are labelled as undifferentiated SpA (uSpA)1,2. In the early 1990s, 2 sets of classification criteria were suggested to encompass the clinical spectrum of SpA: the Amor criteria1 and the European Spondylarthropathy Study Group (ESSG)2 criteria. Each form of SpA may have a late onset3,4. The onset of AS, as defined by the modified New York criteria5, is unusual after the age of 50 years. In a population-based descriptive study carried out in Rochester, Minnesota, USA, the total incidence rate of AS was 7.3 per 100,000 person-years and the incidence value after age 55 years was 2.2/100,000 per year6. In a survey of a large number of members of the German Ankylosing Spondylitis Society, only 6% had the beginning of symptoms after age 40 years7. Only a few studies have compared the clinical expression of late-onset disease with that of earlier onset. In 2001, Brophy and Calin examined the influence of age at symptom onset on disease expression as measured by BASRI (Bath AS Radiology index), BASDAI (Bath AS Disease Activity Index), BASFI (Bath AS Functional index), percentage undergoing AS-related surgery, and prevalence of extraarticular manifestations (uveitis, psoriasis, IBD) in patients with earlier onset (before 21 years of age) and late onset (after 30 years of age)8. Age at onset had no significant effect on radiological progression, disease activity, need for non-hip surgical intervention, and prevalence of extraarticular manifestations. In contrast, there was a significant … Address correspondence to Dr. Olivieri. E-mail: ignazioolivieri{at}tiscalinet.it

Performance of classification criteria for peripheral spondyloarthritis and psoriatic arthritis in the Leiden early arthritis cohort

ObjectivesThe performance of spondyloarthritis (SpA) classification criteria is not well-established in general early arthritis cohorts. Therefore, the authors tested their performance in the Leiden Early Arthritis Clinic (EAC) cohort and...

Performance of the Assessment in Spondyloarthritis International Society Classification for Axial and Peripheral Spondyloarthritis in an Established Clinical Cohort: Comparison with Criteria Sets of Amor and the European Spondylarthropathy Study Group

To evaluate the performance of the Assessment in Spondyloarthritis International Society (ASAS) criteria (axial or peripheral) against the Amor and European Spondylarthropathy Study Group criteria in established spondyloarthritis (SpA). Rheumatologist-diagnosed patients with SpA were retrospectively classified according to the different criteria sets. Clinical characteristics of patients fulfilling all 3 criteria were compared with those who did not, by nonparametric statistics. ASAS classified 90% of the 231 patients, with 169 (73%) fulfilling all 3 criteria sets. Multivariate analysis showed the 62 patients not fulfilling all criteria sets were older at symptom onset (p < 0.001) and less likely to have inflammatory back pain (p < 0.001), peripheral arthritis (p < 0.001), or elevated C-reactive protein levels (p = 0.034). ASAS criteria can be used in established disease.

Clinical features of axial undifferentiated spondyloarthritis (USpA) in China: HLA-B27 is more useful for classification than MRI of the sacroiliac joint

Objectives: To analyse the clinical features of Chinese undifferentiated spondyloarthritis (USpA) patients with predominantly axial involvement, and in particular the influence of human leucocyte antigen (HLA)-B27 and magnetic resonance imaging (MRI) of the sacroiliac joint (SIJ) on the classification of axial USpA.Methods: Patients with low back pain for ≥ 3 months and no definite radiographic sacroiliitis were enrolled in this study. They were diagnosed as USpA based on rheumatologists' findings. Correlations between clinical features and HLA-B27 status or MRI manifestations were analysed.Results: A total of 197 USpA patients were recruited, of whom 135 (70.3%) were positive for HLA-B27. Acute inflammation, structural damage lesions, and normal findings on SIJ MRI were recorded in 64.5, 13.2 and 22.3% of patients, respectively. Classification criteria for axial SpA according to the European Spondylarthropathy Study Group (ESSG), Amor, and the Assessment of SpondyloArthritis International Society (ASAS) were fulfilled by 63.5, 64.5 and 83.2% patients, respectively. Cross-validation showed significant correlation among these three criteria. Patients positive for HLA-B27 included more males, with earlier onset age, better response to non-steroidal anti-inflammatory drugs (NSAIDs), and higher erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP) levels. In addition, more HLA-B27-positive than HLA-B27-negative patients fulfilled the ESSG, Amor, and ASAS criteria. Patients with acute inflammation on SIJ MRI had a higher level of ESR/CRP, and a greater proportion of them fulfilled the Amor and ASAS criteria. However, the proportion of those fulfilling the ESSG criteria did not differ with different MRI manifestations.Conclusion: Both HLA-B27 status and SIJ MRI findings influence the classification of Chinese axial USpA patients, but HLA-B27 seems of more value.

From Retrospective Analysis of Patients with Undifferentiated Spondyloarthritis (SpA) to Analysis of Prospective Cohorts and Detection of Axial and Peripheral SpA

Spondyloarthritis (SpA) refers to a group of HLA-B27-positive associated rheumatic diseases that share clinical and genetic features. The diseases and conditions that constitute the SpA group are defined by signs, symptoms, and radiographic findings, and consist of ankylosing spondylitis (AS), reactive arthritis (ReA), the SpA subsets psoriatic arthritis (PsA), Crohn’s disease (CD) and ulcerative colitis, and a subgroup of undifferentiated forms1. Traditionally, patients with SpA may be classified according to Amor, et al 2 and the European Spondylarthropathy Study Group (ESSG)3 criteria. Patients fulfilling such criteria may then be classified or diagnosed according to specific criteria, clinical picture, or diagnostic tests for AS, ReA and SpA subsets PsA, CD and ulcerative colitis, for example. In general, patients with SpA that do not fulfill such classification or diagnostic-specific criteria remain unclassified and comprise the subgroup known as undifferentiated SpA (USpA). USpA accounts for a significant but variable proportion of patients with SpA in the open population4,5, in a group of relatives of probands with AS6,7, and in hospital-based registries of SpA8–10. As a group, USpA are mostly characterized by isolated episodes of peripheral arthritis and enthesitis, axial symptoms, and by a lower incidence of HLA-B27 versus AS. As a group, SpA are characterized by overlapping of clinical manifestations over the disease course11. For example, patients with AS may develop psoriasis and CD, patients with ReA may develop psoriasis, and patients with psoriasis may developed CD and AS. Similarly, patients with USpA may develop any specific clinical manifestation and fulfill specific diagnostic criteria some time later. In this context, it is clear that patients with SpA fulfilling specific criteria of more than 2 SpA constitute a “true SpA overlap,” while patients presenting with nonspecific or …

Profile of Indian Patients with Juvenile Onset Chronic Inflammatory Joint Disease Using the ILAR Classification Criteria for JIA: A Community-based Cohort Study

To assess the current International League of Associations for Rheumatology (ILAR) classification criteria (Edmonton, 2001) for juvenile idiopathic arthritis (JIA) in Indian patients. Out of 441 children, 330 with chronic joint pains were diagnosed with juvenile onset chronic inflammatory arthritis and followed in an observational cohort. Our study was carried out from 1994 to 2006 in a community rheumatology clinic. Emphasis was placed on obtaining data required by the ILAR system. Of the original group, 235 children were eventually classified as having JIA; 108 were examined during the first year of illness. We assigned 224 children (95%) to discrete JIA categories: enthesitis-related arthritis (ERA; 36%), oligoarthritis (OLA-persistent; 17%), polyarthritis rheumatoid factor (RF)-negative (17%), polyarthritis RF-positive (12%), systemic arthritis (8%), OLA-extended (4%), and psoriatic arthritis (1%). The remaining 11 children (5%) were classified with undifferentiated arthritis (mostly an overlap due to seropositive RF and/or HLA-B27). The prevalence of ERA (89% HLA-B27-positive) and seropositive RF was unexpectedly high. Although agreement (kappa > 0.79) with the American College of Rheumatology criteria and the European Spondylarthropathy Study Group criteria was good to excellent, the ILAR system was found to be more comprehensive and clinically homogeneous. However, some problems appear unique in our scenario. A wide-spectrum phenotype of JIA is demonstrated by an Indian cohort. Although useful, RF and HLA-B27 in this population proved problematic to the ILAR classification.

Classification of rheumatologic opinion on early inflammatory arthritis: Harmonization of a heterogeneous standard

Interrater variability limits rheumatologic opinion as a reference standard for early inflammatory arthritis (IA) classification. The study objectives were to determine whether rheumatologic opinion is associated with potential early IA classification methods despite high interrater variability, and to compare the relative strengths of those associations. Eighteen rheumatologists independently classified 30 initial rheumatology presentation summaries as early IA or not and recommended a pharmacotherapy. Case fulfillment of the following classification methods was independently determined: early referral to rheumatology recommendation for rheumatoid arthritis (ERRR), common early IA cohort inclusion criteria (CEAC), and prevalent IA classification criteria (American College of Rheumatology [ACR]/European Spondylarthropathy Study Group [ESSG]). Associations between rheumatologic opinion, disease-modifying antirheumatic drug (DMARD) recommendation, and each classification method were determined. Participating rheumatologists published on early IA and represented 3 continents. The median case was age 43 (interquartile range [IQR] 30-53) years, had 40 (IQR 24-104) weeks of symptoms, 60 (IQR 18-120) minutes of morning stiffness, a swollen joint count of 6 (IQR 1-13), and an erythrocyte sedimentation rate of 25 (IQR 10-51) mm/hour. The mean ± SD multiple-rater kappa for rheumatologic opinion on early IA was 0.16 ± 0.02. The common odds ratios for associations between rheumatologic opinion and ERRR, CEAC, and ACR/ESSG were 10.3 (95% confidence interval [95% CI] 4.6-23.2), 4.4 (95% CI 2.5-7.7), and 0.7 (95% CI 0.4-1.1), respectively. Odds ratios for associations between DMARD recommendation and ERRR, rheumatologic opinion, CEAC, and ACR/ESSG were 18.7 (95% CI 8.1-43.2), 10.6 (95% CI 6.0-18.8), 2.8 (95% CI 1.7-4.6), and 0.5 (95% CI 0.3-0.7), respectively. Classification methods can be used to harmonize rheumatologic opinion of early IA despite high interrater variability. The ERRR is very strongly associated with both rheumatologic opinions of early IA and DMARD treatment recommendations.