ObjectivesTo study the joint distribution and clinical picture of rheumatoid arthritis (RA) at the initial presentation in seropositive (anti-citrullinated protein antibody (ACPA) and/or rheumatoid factor (RF) positive) and negative patients and the effect of duration of symptoms on the clinical picture.MethodsData of patients who received reimbursement for DMARDs for newly diagnosed RA in 1/2019 to 9/2021 were extracted from the national databases. Joint counts, presence of symmetrical swelling, other disease activity measures, and patient reported outcomes (PROs) were compared in seropositive and negative patients. Regression analyses were applied to compare clinical variables in patients with duration of symptoms of <3, 3–6, and >6 months, adjusted for age, sex, and seropositivity.ResultsData of 1816 ACPA and RF-tested patients were included. Symmetrical swelling was present in 75% of patients. Seronegativeversuspositive patients had higher value for all disease activity measures and PROs including median swollen joint count (SJC46 10versus5) and DAS28 (4.7versus3.7), (p<0.001). Patients diagnosed in <3 months had higher median pain VAS (62versus52 and 50, p<0.001) and HAQ (1.1versus0.9 and 0.75, p = 0.002) compared to those with a duration of symptoms of 3–6 and >6 months. Patients diagnosed >6 months were ACPA-positive more frequently (77%versus70% in other groups, p = 0.045).ConclusionIncident RA presents mainly as symmetric arthritis. Seronegative patients have higher disease burden at the initial presentation. Patients experiencing more severe pain and decreased functional ability are diagnosed earlier, regardless of ACPA- status.