2025 EULAR/ACR Risk Stratification Criteria for At-Risk Arthralgia

Jack Cush, MD

Jun 09, 2025 12:41 pm

A collaborative EULAR/ACR expert panel has established criteria for arthralgia patients at risk (clinically suspect arthralgia) to progress to chronic rheumatoid arthritis (RA). Risk stratification of CSA patients may be instrumental in preventing RA.

A EULAR and ACR expert committee was established. The final expert committee included 20 rheumatologists, 2 fellows, 1 EMEUNET representative, 4 patient research partners, 2 allied health professionals, 1 methodologist, and 2 statisticians, from 10 European countries and North America.

Risk factors for progression to RA were drawn from 10 arthralgia cohorts (including clinically suspect arthralgia and autoantibody-positive arthralgia). The validated risk stratification criteria were developed with a focus was on the risk of progression to clinically apparent inflammatory arthritis (IA) within 1 year, using clinical and serologic variables, without and with subclinical joint inflammation detected by ultrasound (US) or magnetic resonance imaging (MRI).

A total of 2583 arthralgia at-risk persons (from 10 cohorts) were included - of these IA developed in 389 persons (17%) (282 ACPA positive, 107 ACPA-negative persons) within 1 year.

The dataset included 2293 symptomatic at-risk individuals. Risk stratification included 6 clinical and serologic variables with an area under the curve (AUC) of 0.80 (95% CI, 0.77-0.83) for IA development.

morning stiffness (2 points 30-60 min; 4 points > 60 min)
patient-reported joint swelling (4 points)
difficulty making a fist (5 points)
C-reactive protein (1 point)
rheumatoid factor (Low pos 2 points; High poditive 4 points)
anti-citrullinated peptide antibody) (Low pos. 4 points; high positive 8 points))

While inclusion of US did not increase the yield, MRI subclinical inflammation increased the AUC to 0.87 (95% CI, 0.82-0.90).

With a simplified risk stratification score of >10 points (using the MRI_, these 6 variables had a sensitivity and specificity of >75% for IA. For RA, the AUC of the criteria with MRI was 0.93 (95% CI, 0.90-0.97).

These risk stratification criteria are validated and intended to support future prevention trials.