Recommendation Box 2. Information provided to delegates for anonymous comment: commonly used terms that are currently used to describe individuals in phases before the development of RA. Delegates were asked to state whether they felt the terms were useful and to comment further on them. ▶ Pre-RA ▶ Preclinical RA ▶ Inﬂammatory arthralgia ▶ Autoantibody-positive arthralgia ▶ Undifferentiated arthritis autoimmunity associated with RA, but if assessed in patients in that phase would not be a risk factor for progression though to the development of RA. In contrast, a different risk factor may be relevant to progression from unclassiﬁed arthritis to the development of RA. Using the knowledge of risk factors important in each phase, risk stratiﬁcation and prediction mod- els might identify those individuals who would beneﬁt from intervention applicable to that phase. Prediction of clinically relevant outcomes in addition to the development of RA The heterogeneous nature of RA was acknowledged and it was agreed that, in addition to predicting the development of RA, research should look at biomarkers and risk factors for the rate of progression of joint destruction and the development of extra-articular manifestations of RA (eg, cardiovascular disease and pulmonary ﬁbrosis) that could be identiﬁed in individuals ‘at risk’ of RA. Factors related to remission would also be of inter- est. The possible inﬂuence of the timing and intensity of therapy on these longer-term outcomes should be acknowledged. Systemic autoimmune phase and site(s) of disease initiation The term ‘systemic autoimmunity associated with RA’ was felt to be the best to describe the phase during which abnormali- ties in various body compartments can be found preceding the clinical expression of the disease. Although the synovium is the principal site of pathology in the established phase of disease, it may not be the site where the disease is initiated. Systemic immune abnormalities in individuals without joint symptoms, and a lack of immune inﬁltrates in the synovium during the ear- liest phase before clinical signs and symptoms of arthritis,7 point to other tissues being important in the initiation of adaptive immune reactions. Important tissues for research include bone marrow, lymph nodes, the gut, periodontal tissue,11 the lung8 and the neuroendocrine system. An initial phase, characterised by systemic autoimmunity without synovial inﬂammation, may be followed by a shorter phase during which asymptomatic syn- ovitis is present.12 13 Based on the results of research on various tissues during different stages of the disease, it may be possible to develop speciﬁc preventive interventions targeting the break- ing of tolerance or the formation of autoantibodies. Symptoms without clinical arthritis phase It was widely recognised that many patients with RA have a period of symptoms likely to be related to the development of inﬂammatory joint disease before they develop clinical arthri- tis. Two important areas for research were identiﬁed within this 640 Box 3. Recommendation for terminology to be used to deﬁne speciﬁc phases up to the development of RA ▶ In prospective studies individuals would be described as having: (a) Genetic risk factors for RA (b) Environmental risk factors for RA (c) Systemic autoimmunity associated with RA (d) Symptoms without clinical arthritis (e) Unclassiﬁed arthritis (f) RA ▶ The term ‘arthritis’ is used to denote clinically apparent soft tissue swelling or ﬂuid (not bony overgrowth alone). ▶ (a) to (e) can be used in a combinatorial manner for example, an individual may have (a)+(b), or (a)+(b)+(c) or (a)+(b)+(d), etc. ▶ The preﬁx ‘pre-RA with:’ can be used before any/any com- bination of (a) to (e) but only to describe retrospectively a phase an individual was in once it is known that they have developed RA. phase. First, the signiﬁcance of synovial and bone abnormali- ties as assessed by imaging (eg, ultrasound or MRI), which may detect changes such as synovial thickening, increased synovial vascularity and bone marrow oedema in patients with symp- toms without clinical arthritis, as predictors of progression to unclassiﬁed arthritis and the development of RA. Second, the importance of identifying symptoms/complexes of symptoms that are associated with the subsequent development of RA. DISCUSSION The characterisation of genetic and environmental risk factors for RA, and the identiﬁcation of blood-based biomarkers predic- tive of development of RA in as yet asymptomatic individuals, has led to increasing interest in the development of predictive and preventive strategies that can be used before the onset of symptoms. This comes against a background of considerable research looking at predictive and therapeutic approaches in patients with symptoms before they fulﬁl the classiﬁcation cri- teria for RA.6 14–19 These criteria9 10 have allowed for a common understanding of what we mean by this phase in the patient’s journey. There is, however, a plethora of terms currently used to describe individuals in disease phases before the fulﬁlment of classiﬁcation criteria for RA, including ‘early RA’, ‘very early RA’ and ‘pre-RA’. The recommendations in this paper propose guidance on approaches to describe speciﬁc phases before the development of RA, which are inﬂuenced by our current thinking about aetiopathogenesis. The use of these terms in the manner suggested will facilitate communication between researchers and comparisons between studies, in much the same way that classiﬁcation criteria facilitate recruitment of patients with similar clinical phenotypes to clinical trials. An important outcome from the meeting was a decision to rec- ommend that the use of the term ‘pre-RA’ should be limited to very speciﬁc situations. To reﬂect this, the original name of the study group (Study Group for Preclinical and the Earliest Clinically Apparent Phases of Rheumatoid Arthritis) has been changed to Study Group for Risk Factors for Rheumatoid Arthritis. Ann Rheum Dis 2012;71:638–641. doi:10.1136/annrheumdis-2011-200990