Various prognostic factors for poor outcome have been identified in patients with RA, but poor prognostic factors are most applicable to the untreated natural history of the disease. The most reliable prognostic factor is anti-cyclic citrullinated peptide (anti-CCP) antibody positivity, which is observed in approximately 75% of patients with RA and suggests not only that the patient really has RA but also aggressive erosive disease. Further, those who are double positive for both anti-CCP antibody and rheumatoid factor (RF) and who have joint erosions have particularly aggressive disease; these individuals require aggressive therapy and will have poor clinical outcomes if they do not receive appropriate treatment. Even double-positive patients, however, have a good prognosis if they are treated appropriately, so it is important to treat all patients early and aggressively once they have been diagnosed with RA. The medical community has learned over the last 20 years that all individuals with RA should be treated to a target of low disease activity or remission, regardless of their baseline prognostic indicators. If patients can achieve a low disease activity, they will do extremely well. When I see patients with new-onset RA, I am actually encouraged if they are anti-CCP positive because I know exactly what is wrong with them and I feel confident in my ability to help them achieve remission with the appropriate and well-tolerated medications.

Data indicate that patients who are negative for anti-CCP and RF have a better overall prognosis, yet we also know that seropositive patients are precisely the patients for whom certain biologicals work best. The real challenge is identifying the right medication for each individual because none of the prognostic factors have been shown, to date, to be useful for guiding treatment decisions and predicting which medication is the most appropriate for any individual patient. The main prognostic factor that I use in the management of patients who have already started treatment is the number of tender and swollen joints. If a patient still has tender/swollen joints even after he or she has started a particular therapy, I know that a change of therapy is indicated. An important goal of future research is to identify prognostic factors that can predict a patient’s differential response to therapies. When we are able to do this, RA therapy will take a huge leap forward.