Rheumatoid Arthritis (RA) is classified as severe when it significantly impacts the patient’s quality of life, physical function, or when there is evidence of rapidly progressing joint damage. Here’s how severity might be assessed to justify the use of Disease-Modifying Antirheumatic Drugs (DMARDs):

• Clinical Symptoms:
• High Disease Activity: Measured by scores like the Disease Activity Score 28 (DAS28), where a score above 5.1 generally indicates high disease activity.
• Persistent or Severe Symptoms: Continuous joint pain, swelling in multiple joints, morning stiffness lasting more than an hour, and significant fatigue or malaise.
• Functional Impairment:
• Disability: Impact on daily activities, work, or self-care, often assessed by tools like the Health Assessment Questionnaire (HAQ).
• Joint Damage:
• Radiographic Evidence: X-rays or MRI showing erosions, joint space narrowing, or other signs of structural damage to the joints.
• Systemic Involvement:
• Extra-articular Manifestations: Presence of symptoms outside the joints, like rheumatoid nodules, vasculitis, pleuritis, pericarditis, or Felty’s syndrome.
• Laboratory Findings:
• Seropositivity: High levels of rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) antibodies, which are associated with more aggressive disease.
• Response to Treatment:
• Lack of Response to Initial Therapy: If less aggressive treatments like non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids are not effective in controlling symptoms or preventing progression.

DMARDs are typically introduced early in the course of RA to prevent joint damage and disability, but they are especially considered in:

• Early Aggressive Disease: To halt progression when there’s evidence of rapid joint damage or high disease activity early in the disease course.
• Failure of Conventional Therapy: When first-line treatments do not adequately control the disease.
• Poor Prognostic Factors: Presence of factors like seropositivity, high disease activity, or early erosions which predict a more aggressive disease course.

The decision to use DMARDs, particularly more aggressive or biologic DMARDs, is usually made in consultation with a rheumatologist who can assess the totality of the patient’s condition, including the above factors.

Disclaimer: not a doctor; please consult a medical professional. Do not share your personally identifiable information.