Presentation: Would prior testing of Anti-Cyclic Citrullinated Antibodies (anti CCP) Help with Decision Making at the First Visit to an Early Arthritis Clinic? (2007)

1825 Would prior testing of Anti-Cyclic Citrullinated Antibodies (anti CCP) Help with Decision Making at the First Visit to an Early Arthritis Clinic?

PURPOSE: To evaluate if knowing anti-CCP status could help management decisions at first visit to an EAC.
METHODS: This EAC accepts patients with symptom duration <1 year and any one of the following, 3 objectively swollen joints, early am stiffness 30 minutes or a positive “squeeze test”. Blood tests before first visit include Rheumatoid Factor (RF). In 100 consecutive new patients the pre-visit samples were tested retrospectively for anti CCP. Records from each first visit were reviewed separately by three accredited Rheumatologists and a Specialist Nurse, all were “blinded” to the anti CCP result. Treatment given at that first visit was recorded. Each reviewer then independently recorded the treatment strategy they would have followed had the anti CCP result been available. The treatments suggested by the reviewers were then compared to see if there was “consensus” and where there was consensus this was compared with the actual treatment strategies.
RESULTS: 98 patients had sufficient documentation for the review. The actual treatment strategies were; Discharge no treatment 8; Alternative systemic disease 3; Observe in clinic after interval with no treatment 15; Intra articular injection 2; Corticosteroid trial (oral or intramuscular) 45; Treat with monotherapy as sulfasalazine or hydroxychloroquine (HCQ) 5; Start standard DMARD treatment as Methotrexate (MTX) 10mgs +/- HCQ same day 15; Start intensive DMARD as prednisolone 20-30mg plus MTX with rapid dose escalation + HCQ 4.
After seeing the anti CCP results 4 of 4 reviewers’ suggestions were identical in 30 cases, 3 out of 4 reviewers agreed in 47 cases and 2 of 4 in 8 cases. In 12 cases there was no agreement.
Had the suggested strategies been implemented the outcomes would have been; Discharge no treatment 21; Alternative systemic disease 3; Observe in clinic after interval with no treatment 4; Intra articular injection 1, Corticosteroid trial 23; Treat with monotherapy 3; Start standard DMARD treatment 19; Start intensive DMARD as prednisolone 11. 13 extra patients would have been immediately discharged; of 47 patients given a trial of corticosteroid 5 would have started standard and 3 intensive DMARDs, 1 been injected and 5 discharged (in 10 there was no agreement). Of 15 given standard DMARDS 8 would have been upgraded to intensive treatment. Only 6 patients strategies were changed in RF negative patients found to be antiCCP positive. CONCLUSION; With knowledge of the anti CCP status at time of first visit the number of discharges would be increased from 7 to 13 of 97 referrals to the clinic. Same day starts of definitive combination DMARD treatment would increase from 19 to 28 patients. Testing of anti CCP status before first visit is potentially very useful to decide on initial management in the EAC, avoiding trials of corticosteroid and shortening time to start of combination DMARDs.

D. O'Reilly, Shering-Plough, Roche, Servier, 5 Consulting fees; Grants from same to department, 9 Other.