Is it Time to Label ‘At Risk of Rheumatoid Arthritis’ a Disease?

Rheumatoid arthritis (RA) is increasingly recognised as the final stage of a prolonged disease continuum that may begin years before the onset of clinically apparent synovitis. During this at-risk phase, individuals without clinical synovitis may present with autoantibodies, musculoskeletal symptoms, systemic inflammation, and subclinical synovitis detectable on imaging. Emerging evidence suggests that this phase is associated not only with an increased risk of progression to RA, but also with a substantial clinical, psychological, and socioeconomic burden. This viewpoint examines evidence on at-risk individuals who frequently report fatigue, pain, impaired function, reduced quality of life, and psychological distress, often comparable to patients with early RA. Imaging studies also demonstrate frequent subclinical synovitis associated with progression risk and functional impairment. Qualitative studies further highlight the emotional burden related to uncertainty and risk awareness. Finally, economic analyses suggest substantial societal costs, largely driven by reduced work productivity. Recent interventional trials have shown that early therapeutic intervention can improve symptoms, imaging findings, and patient-reported outcomes, while reducing progression to inflammatory arthritis in selected populations. These findings support the concept that the at-risk phase represents a biologically and clinically meaningful condition. Different approaches to defining and classifying the at-risk phase of RA, including stage-based models, are discussed alongside challenges related to terminology. Recognising the at-risk phase of RA as a disease entity could facilitate earlier intervention strategies, improve patient outcomes, and support the development of clearer clinical management pathways.