Rheumatol Int
DOI 10.1007/s00296-012-2515-0
SHORT COMMUNICATION
How much difference does the age at onset make in early arthritis
patients? Comparison between the ACR 1987 and the ACR/
EULAR 2010 classification criteria for rheumatoid arthritis
at the time of diagnosis
Maria-Magdalena Tamas • Ioana Felea •
Simona Rednic
Received: 28 February 2012 / Accepted: 23 August 2012
Ó Springer-Verlag 2012
Abstract The age at onset in early arthritis (EA) may
influence the disease activity and its evolution. The aim of
the current study is to identify possible differences
regarding the ‘‘old’’ and the ‘‘new’’ classification criteria
between patients with early-onset and late-onset early
arthritis. The study included 64 patients. They were divided
in two groups, according to the mean age: early-onset
EA—less or equal than 45 years old (group A) and late-
onset EA—over 45 years old (group B). The ‘‘old’’ criteria
as well as the ‘‘new’’ ones were assessed for all patients, at
the time of the first visit to the rheumatologist. The initi-
ation of treatment with Methotrexate was used as ‘‘gold
standard’’ to calculate the sensitivity and the specificity of
both criteria. ‘‘New’’ criteria were fulfilled in 51 % (A) and
72 % of cases (B), while ‘‘old’’ criteria were fulfilled in
37 % of patients (A) and 62 % (B). Methotrexate was
initiated in 82 % of patients (B) and in 51 % (A), p = 0.01.
‘‘New’’ criteria demonstrated a sensitivity of 77.7 %
(A) and 83.3 % (B), while ‘‘old’’ criteria had a sensitivity
of 50 % (A) and 66.6 % (B). Patients with late onset
had significantly higher disease activity scores: 76 %
(B) versus 40 % (A), p = 0.04. The sensitivity and the
specificity of the ‘‘new’’ criteria for RA are comparable in
patients with early-onset and late-onset EA, and the sen-
sitivity of these criteria is increased compared to the ‘‘old’’
criteria. Patients with late onset fulfilling the ‘‘old’’ criteria
had poor prognostic factors and higher disease activity at
the time of diagnosis, which may have possible implica-
tions for the disease course.
M.-M. Tamas (&)
I. Felea
S. Rednic
Department of Rheumatology, ‘‘Iuliu Hatieganu’’
University of Medicine and Pharmacy, Cluj-Napoca, Romania
e-mail: mm_tamas@yahoo.com
Keywords Early arthritis
Early-onset early arthritis

Late-onset early arthritis
Classification criteria
Introduction
Early arthritis (EA) represents an inflammatory arthritis
with recent onset, which does not fulfill the classification
criteria for any definite rheumatological disorder. The
disease course may be toward rheumatoid arthritis (RA),
other rheumatic autoimmune diseases or toward remission.
There is increasing evidence that early diagnosis and early
aggressive treatment can limit RA progression and sever-
ity. The age at onset in early arthritis (EA) may influence
the disease activity and its evolution. New classification
criteria for RA have been developed by the American
College of Rheumatology (ACR) and the European League
against Rheumatism (EULAR), in order to early identify
patients who would benefit of more aggressive intervention
[1, 2]. The former 1987 ACR criteria for RA were con-
sidered not sensitive enough in early disease [3]. There are
several published studies in which different algorithms
were described in order to identify markers for persistence
and severity of the disease [4, 5]. Gender was identified as
a poor prognostic factor; male patients being considered a
marker for the persistence of the disease [6]. There are few
published data regarding the impact of the age at onset on
the disease activity and its evolution [6–8].
An early classification of the disease should be equally
important, regardless the age at onset. The aim of the
current study is to identify possible differences between
early-onset and late-onset early arthritis patients, fulfilling
1987 ACR Rheumatoid Arthritis (RA) criteria and/or the
2010 ACR/EULAR classification criteria at the time of the
first visit to the rheumatologist.
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Methods
Patients
Patients between 18–75 years of age with arthritis of at
least one peripheral joint less than 12 months duration
were included in the study. Other definite causes for
arthritis were excluded: definite spondylarthritides, definite
connective tissue diseases, microcrystal-induced arthritis,
paraneoplastic syndromes, osteoarthritis and trauma.
Study design
The study was conducted in the Rheumatology Department of
a tertiary referral center in Romania between January 2009
and May 2011. Patients were divided in two groups, according
to the mean age: early-onset EA—less or equal than 45 years
old (group A) and late-onset EA—over 45 years old (group
B). The ACR 1987 (‘‘old’’) criteria as well as the 2010 ACR/
EULAR (‘‘new’’) classification criteria for RA were assessed
for all patients, at the time of the first visit to the rheumatol-
ogist. The initiation of treatment with Methotrexate was used
as ‘‘gold standard’’ to calculate the sensitivity and specificity
of both criteria. The study was conducted according to the
Declaration of Helsinki and local regulations. Approval of
the institutional ethics committee was requested and
informed consent was obtained from all patients.
Clinical assessment and laboratory investigations
Complete clinical examination was performed in order to
exclude other possible causes for arthritis. 28 joints were
clinically assessed for tenderness and swelling. Global
status of the disease activity reported by patients and
duration of morning stiffness were recorded.
C-reactive protein (CRP) (normal level \ 0.5 mg/l),
erythrocite sedimentation rate (ESR) (normal level \ 20
mm/1st hour) as well as IgM rheumatoid factor (RF) (normal
level \ 32 UI/ml) and anti-cyclic citrullinated peptide (anti-
CCP) (normal level \ 3 UI/ml) antibodies were determined.
Disease activity score 28 (DAS 28) was calculated
for all patients
Statistical analysis was performed using Microsoft Excel
and Epi Info 3.5.1.
Results
Table 1 summarizes patients’ demographic, clinical and
laboratory data, in the two groups of subjects, fulfilling the
‘‘old’’ or the ‘‘new’’ criteria.
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Rheumatol Int
The study included 64 patients (F/M, 3/1; mean age,
45 years; mean disease duration, 3 months; 35 patients
early-onset EA—group A; 29 patients late-onset EA—
group B). New criteria were fulfilled in 51 % (A) and 72 %
of cases (B), while old criteria were fulfilled in 37 % of
patients (A) and 62 % (B) (Table 1).
More women with late onset fulfilled the old criteria:
62 % (B) versus 30 % (A), p = 0.03. Shorter disease
duration was observed in patients with late-onset RA
compared to early-onset RA, fulfilling the new criteria: 2.8
versus 3.8 months. Patients from group B also had an
increased number of tender and swollen joints, compared to
the other group, irrespective to the criteria fulfilled, but not
statistically significant (Table 1). Increased C-reactive
protein levels were seen in patients with late onset, ful-
filling the old criteria: 78.5 % (B) versus 35 % (A),
p = 0.01. These patients also had significantly higher
DAS28 scores at baseline: 76.4 % (B) versus 40 % (A),
p = 0.04. Positive anti-CCP antibodies were detected in
58.6 % of late-onset EA patients fulfilling the new criteria
versus 42.8 % early-onset RA group. The results also
showed the same distribution of RF 51.7 versus 31.4 %
(Table 1). Patients fulfilling the new criteria received MTX
in 81 % group B versus 66.6 % group A (Table 1).
Table 2 shows the statistical analysis of the ACR 1987
Criteria and the ACR/EULAR 2010 Criteria in patients
with early-onset and late-onset EA.
Discussion
The results of the present study show that the sensitivity
and the specificity of the 2010 ACR/EULAR classification
criteria for RA were comparable in early-onset and late-
onset EA. Our study demonstrates that the sensitivity of the
new criteria is increased compared to the 1987 ACR cri-
teria, irrespective to the age at onset. A superior sensitivity
of the new criteria over the 1987 criteria was previously
demonstrated [9, 10]. Our results also show a higher
specificity of the 2010 ACR/EULAR compared to the 1987
ACR in patients with late-onset RA.
Both sets of criteria were more frequently fulfilled in
late-onset EA patients. This observation suggests that in
younger patients, the diagnosis might be more difficult at
the first visit. One possible explanation can be that EA in
younger patients may represent an early stage of a con-
nective tissue disease, seronegative spondyloarthritides, or
a self-limiting disease. On the other hand, the criteria for
RA might be fulfilled later during the evolution of the
disease [1].
Although the age of late-onset RA is generally consid-
ered above 60, in the present study, we divided the two
groups according to the mean age, in order to have a
Rheumatol Int

Table 1 Patients’ demographic, clinical and laboratory data in early-onset RA and late-onset RA groups
Characteristics Early-onset EA (Group A) Late-onset RA (Group B)
Criteria for RA 1987 ACR 2010 ACR/EULAR 1987 ACR 2010 ACR/EULAR

Number of patients 13 18 18 21
Diagnosis of RA (%) 37 51 62 72
Demographic and clinical variables
Women (%) 30* 51.8 62* 76.2
(*p = 0.03)
Disease duration (months) 4.2 3.8 3 2.8
Morning stiffness [30 min (%) 52.3 62 83.3 88.8
Tender joint count (mean) 10.2 9.7 12.6 12.4
Swollen joint count (mean) 7.3 6.5 8.5 8.1
Symmetric arthritis (%) 57.1 66.6 66.6 74
[3 joints involved (%) 52 64 72 84
DAS 28 C 3.2 (%) 40* 60 76.4* 88.2
(*p = 0.04)
Methotrexate (%) 50 66.6 77.7 81
Laboratory variables
ESR [ 20 mm/1st hour (%) 42 52.6 71.4 76.2
CRP [ 0.5 mg/l (%) 35* 55 78.5* 78.5
(p = 0.01)
IgM RF positive (%) 20 31.4 44.8 51.7
Anti-CCP antibodies positive (%) 31.4 42.8 41.3 58.6

Table 2 Statistical analysis of the ACR 1987 Criteria and the ACR/EULAR 2010 classification criteria in patients with early-onset and late-
onset EA
Early-onset EA (Group A) Late-onset EA (Group B)
1987 ACR 2010 ACR/EULAR 1987 ACR 2010 ACR/EULAR

Sensitivity (Se) 50 % 77.7 % 66.6 % 83.3 %

Specificity (Sp) 75 % 75 % 60 % 80 %
Positive predictive value (PPV) 69 % 77.7 % 88 % 95 %
Negative predictive value (NPV) 57 % 75 % 27 % 50 %
Likelihood ratio (LR)? 2 3.11 1.66 4.16
Likelihood ratio (LR)- 0.66 0.29 0.55 0.20
Accuracy (AC) 61.7 % 76.4 % 65.5 % 82.7 %

balanced number of subjects in each group. The diagnosis
of RA was established easier in female patients with late-
onset EA, by fulfilling the 1987 ACR criteria, probably
explained by the fact that a significant number of subjects
had a hand involvement, in a symmetric fashion, with more
than 3 joints affected. Other studies found hand involve-
ment as the most frequent site affected in both early-onset
and late-onset RA [11]. This explanation might sustain also
the fact that a high number of patients in our cohort fulfilled
the old criteria despite the short duration of the disease.
Our results show that patients with late-onset EA had
higher disease activity scores compared to the early-onset
group. Other studies did not find differences according to
the age at onset in RA [12, 13]. Calvo Alen et al. [13]
suggest that, however, disease compounded by age-asso-
ciated factors may have a worse prognostic late than early
in life. In the paper of Chen et al. [14], elderly patients
were found to have different characteristic of the clinical
features of RA as well as differences in the patterns of pro-
inflammatory cytokines, compared to younger patients.
We observed that a higher number of patients from
group B had anti-CCP antibodies and RF positive, but there
were no significantly differences between the two groups
fulfilling either old or new criteria regarding their presence.

123

Other published data showed that younger-onset EA was
associated with the presence of anti-CCP antibodies or
rheumatoid factor [6, 7].
The results of the present study revealed that patients
with late-onset EA have more markers for severity, as other
published studies already demonstrated [12, 13]. These
patients also fulfilled the old criteria, suggesting that the
diagnosis of definite RA is more frequent in this age group,
compared to the other. The initiation of MTX treatment in
these cases was also supported by the presence of poor
prognostic factors. The results are similar to those of the
study of Tutuncu et al. [12], MTX being prescribed more in
late-onset RA patients, but in lower doses compared to
younger patients. We considered the initiation of MTX
treatment as a marker for a persistent or severe arthritis.
The close monitoring of patients by their current rheuma-
tologist allowed changes in therapy, MTX being added
during the follow-up when considered (data not shown).
Several studies highlight the importance of using the new
2010 ACR/EULAR classification criteria in order to allow
a more rapid identification of patients requiring more
aggressive therapy, avoiding over-diagnosis and unneces-
sary treatment with potentially toxic side effects [10].
One limitation of this study is the age of 75 years as the
upper limit for the inclusion criteria. The explanation is that,
in our experience, patients above this age usually develop
polymyalgia rheumatica, microcrystal-induced arthritis or
paraneoplastic syndromes and less rheumatoid arthritis.
Another limitation of the present study is that we used
only the initiation of treatment with Methotrexate as the
‘‘gold standard’’ for calculating the sensitivity and the
specificity of the classification criteria for RA, and not using
also the data from the follow-up, as was already done in other
published studies [9, 10]. One reason is the fact that, in our
practice, Methotrexate is indicated when poor prognostic
factors are present and an aggressive attitude is needed.
Conclusion
The sensitivity and the specificity of the 2010 ACR/EU-
LAR criteria for RA are comparable in patients with early-
onset and late-onset EA. The sensitivity of ACR/EULAR
2010 criteria is increased compared to 1987 criteria, in
early, as well as in late-onset EA. Both sets of criteria were
more frequently fulfilled in patients with late-onset EA.
More patients with late onset fulfilling the ‘‘old’’ criteria
had poor prognostic factors and higher disease activity
scores at the time of diagnosis, which may have possible
implications for the disease course. Studies on larger series
of patients are needed in order to confirm the results.
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Rheumatol Int
Acknowledgments Dr. Maria-Magdalena Tamas was supported by
POSDRU/89/1.5/S/58965 Project, with financial support from The
European Social Fund Project–Operational Programme Human
Resources Development 2007–2013.
Conflict of interest The authors declared no conflict of interests.
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