# A matter arising: When should inflammatory and autoimmune rheumatic diseases be considered ‘early’?

## TL;DR

This review discusses how to identify early signs of inflammatory and autoimmune rheumatic diseases to improve diagnosis and prevent organ damage.

## Contribution

The paper provides updated insights into early diagnostic strategies for rheumatoid arthritis, systemic sclerosis, and large-vessel vasculitis in polymyalgia rheumatica.

## Key findings

- Musculoskeletal ultrasound and MRI can detect early synovitis and bone marrow edema in rheumatoid arthritis.
- Raynaud's phenomenon and nailfold capillaroscopy help predict progression to systemic sclerosis.
- Imaging reveals subclinical vasculitis in polymyalgia rheumatica, linked to higher relapse rates.

## Abstract

Early diagnosis is pivotal for guiding the intensity of clinical monitoring, optimizing therapeutic strategies and preventing organ damage in inflammatory and autoimmune rheumatic diseases (IARDs). This review summarizes current evidence on early diagnostic and therapeutic approaches of some IARDs, including rheumatoid arthritis (RA), systemic sclerosis (SSc) and detection of large‐vessel vasculitis (LVV) in polymyalgia rheumatica (PMR), representing distinct pathophysiological mechanisms of joint synovitis, tissue fibrosis and vasculitis, respectively.

A comprehensive narrative literature review was conducted focusing on early recognition strategies, searching PubMed and Scopus databases with emphasis on studies from the past 5 years and recent EULAR/ACR conference abstracts (2023–2025).

In RA, clinically suspect arthralgia with seropositivity for rheumatoid factor and anti‐citrullinated peptide antibodies significantly increases progression risk to definite RA. Musculoskeletal ultrasound detects subclinical synovitis in 44%–51% of high‐risk individuals, while MRI identifies bone marrow edema predicting erosive progression. Abatacept significantly reduces RA development in seropositive individuals at high risk of RA.

In SSc, Raynaud's phenomenon combined with SSc‐specific autoantibodies and abnormal nailfold capillaroscopy predicts progression to definite disease, with 79.5% developing SSc within 4.6 years. LeRoy's criteria, validated by Koenig, enables early identification, though evidence for disease‐modifying interventions in preclinical stages remains limited.

For PMR, imaging reveals subclinical LVV in 16%–23% of patients without cranial symptoms. Subclinical LVV associates with higher relapse rates in retrospective studies, though optimal management approaches require prospective validation.

Advances in early IARD recognition through refined clinical criteria, enhanced biomarkers and imaging enable risk stratification and personalized management. While intervention strategies show promise, particularly in RA, optimal patient selection and treatment protocols require further research.

Timely recognition of inflammatory and autoimmune rheumatic diseases (IARDs) is important to optimize the early diagnosis with tailored interventions and possible prevention of irreversible organ damage. This narrative review provides an update by summarizing the advances in identifying the early stages of rheumatoid arthritis, systemic sclerosis and large‐vessel vasculitis in polymyalgia rheumatica, representing distinct mechanisms of synovitis, fibrosis and vasculitis. Combining clinical, serological and imaging tools enhances early detection of risk factors for progression.