QJM Advance Access originally published online on October 19, 2007
QJM 2007 100(11):737-738; doi:10.1093/qjmed/hcm091
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Anti-CCP antibodies as an aid to prioritization of patients referred to the rheumatology clinic
Sir,As noted in your review article,1 anti-cyclic citrullinated peptide antibodies (CCP) have been shown to be more sensitive and specific for rheumatoid arthritis (RA) than the rheumatoid factor (RF).2 It is also well accepted that patients with early RA should be seen and treated as soon as possible, as there is a window of opportunity for full remission if treated within the first two years.
We operate a prioritization system for patients in a rapid-access rheumatology clinic based on information supplied by GP letters, whereby patients with suspected inflammatory joint disease (IJD) are seen within 2 weeks of referral. This system has been previously audited and shown to be efficient.3 The main problem revealed by the audit was that many patients without IJD were given inappropriately high priority at the request of the GP, often on the basis of a false-positive RF, whereas the clinical information in the letter did not warrant this high priority. Since it is difficult to see all the patients referred by the GPs as urgent within our desired slot of 2 weeks, we examined the possibility that anti-CCP antibody testing could yield more accurate prioritization of patients who needed to be seen early, by avoiding the false high prioritization given by a false-positive RF.
In this prospective observational study, we tested CCP antibodies in 28 RF-positive patients referred by GPs to our rapid-access clinic. On receipt of the letter, a provisional clinical diagnosis was made on the basis of the information given in the letter ('paper diagnosis'), and patients were prioritized to categories A, B, and C. Category A meant that inflammatory joint disease was suspected, and this warranted a clinic appointment within 2 weeks. Category B included established RA patients as well as new patients who needed to be seen within 8 weeks. Category C included patients referred by GPs of low clinical priority, to be seen within current guidelines of 13 weeks. We correlated the final diagnosis on follow-up with results of the anti-CCP antibody test.
Of the 28 patients, five were given a high priority (category A) on the basis of their paper diagnosis. All of these patients had positive anti-CCP antibodies, and were found to have IJD on follow-up. Ten patients were placed in category B: 8 were negative for anti-CCP antibodies and 2 were weakly positive. None of these 10 patients had IJD on follow-up. Finally, 13 patients were thought to have a low clinical priority based on their paper diagnosis. In all of these, anti-CCP antibodies were negative, suggesting that the RF was a false-positive result. None of these 13 patients had inflammatory joint disease on follow-up. This supported the clinical decision not to expedite their assessment.
We therefore recommend that anti-CCP antibody testing is made available for RF-positive patients in the community so that the limited number of high priority slots in rapid-access clinics are not wasted.
Wrightington Hospital
Wigan
UK
email: ayesha.madan{at}wwl.nhs.uk
References
1. Niewold TB, Harrison MJ, Paget SA. Anti-CCP antibody testing, as a diagnostic and prognostic tool in rheumatoid arthritis. Q J Med (2007) 100:193–201.[Web of Science]
2. Avouac J, Gossec L, Dougados M. Diagnostic and predictive value of anti-cyclic citrullinated protein antibodies in rheumatoid arthritis: a systematic review. Ann Rheum Dis (2006) 65:845–51.
3. Sathi N, Whitehead E, Grennan DM. Can a rheumatologist accurately prioritize patients on the basis of information in the general practitioners referral letter? Rheumatology (2003) 42:1270–1.
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