How Are Rheumatologists Managing Anticyclic Citrullinated Peptide Antibodies–positive Patients Who Do Not Have Arthritis?

Mankia, Kulveer; Briggs, Christopher; Emery, Paul

doi:10.3899/jrheum.190211

Cited by 21 publications

(20 citation statements)

References 5 publications

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“…The detection of reliable biomarkers, which help to identify individuals at-risk for future arthritis, is a critical prerequisite for RA prevention trials. It is also important that such biomarkers are readily available to rheumatologists who are now routinely being referred at-risk individuals in clinical practice (20). As such, a focused US examination, which enabled risk stratification in the clinic setting, would be invaluable for managing these patients.…”

Section: Introductionmentioning

confidence: 99%

Ultrasound erosions in the feet best predict progression to inflammatory arthritis in anti-CCP positive at-risk individuals without clinical synovitis

et al. 2020

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ObjectivesTo investigate, in anti-cyclic citrullinated peptide antibody positive (CCP+) at-risk individuals without clinical synovitis, the prevalence and distribution of ultrasound (US) bone erosions (BE), their correlation with subclinical synovitis and their association with the development of inflammatory arthritis (IA).MethodsBaseline US scans of 419 CCP+ at-risk individuals were analysed. BE were evaluated in the classical sites for rheumatoid arthritis damage: the second and fifth metacarpophalangeal (MCP2 and MCP5) joints, and the fifth metatarsophalangeal (MTP5) joints. US synovitis was defined as synovial hypertrophy (SH) ≥2 or SH ≥1+power Doppler signal ≥1. Subjects with ≥1 follow-up visit were included in the progression analysis (n=400).ResultsBE were found in ≥1 joint in 41/419 subjects (9.8%), and in 55/2514 joints (2.2%). The prevalence of BE was significantly higher in the MTP5 joints than in the MCP joints (p<0.01). A significant correlation between BE and US synovitis in the MTP5 joints was detected (Cramer’s V=0.37, p<0.01). The OR for the development of IA (ever) was highest for the following: BE in >1 joint 10.6 (95% CI 1.9 to 60.4, p<0.01) and BE and synovitis in ≥1 MTP5 joint 5.1 (95% CI 1.4 to 18.9, p=0.02). In high titre CCP+ at-risk individuals, with positive rheumatoid factor and BE in ≥1 joint, the OR increased to 16.9 (95% CI 2.1–132.8, p<0.01).ConclusionsIn CCP+ at-risk individuals, BE in the feet appear to precede the onset of clinical synovitis. BE in >1 joint, and BE in combination with US synovitis in the MTP5 joints, are the most predictive for the development of clinical arthritis.

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Section: Introductionmentioning

confidence: 99%

Ultrasound erosions in the feet best predict progression to inflammatory arthritis in anti-CCP positive at-risk individuals without clinical synovitis

et al. 2020

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“…The longitudinal scan of the flexor digitorum tendons shows the presence of synovial hypertrophy (asterisks) and synovial effusion (rounded dots) in the synovial tendon sheath. Legend: fdt, flexor digitorum tendons highly variable [8]. Both over-treatment and under-treatment will therefore naturally ensue, according to the clinical intuition of the rheumatologist.…”

Section: The Utility Of Ultrasound In Managing Individuals At-risk Ofmentioning

confidence: 99%

“…In the absence of trial evidence, the optimum management of these patients is not yet clear. However, in practice, rheumatologists are already using US intuitively to guide the management of these patients; if US synovitis is identified, clinicians often consider starting treatment rather than monitoring for progression [8]. Clearly, there is a significant risk of overtreatment with this approach as many of these symptomatic at-risk patients may not go on to develop clinical synovitis, especially within the short term.…”

Section: The Utility Of Ultrasound In Managing Individuals At-risk Ofmentioning

confidence: 99%

The Role of Musculoskeletal Ultrasound in the Rheumatoid Arthritis Continuum

et al. 2020

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Purpose of Review Rheumatoid arthritis (RA) is no longer considered a fixed phenotype but rather a disease continuum. This review outlines the current and potential value of applying ultrasound (US) along this continuum: from the prediction of progression to RA in at-risk individuals, to confirmation of the early diagnosis of RA, as well as the consideration of differential diagnoses, and the use in disease monitoring and defining remission. Recent Findings In individuals at-risk of RA (i.e., positive autoantibodies with symptoms but without synovitis), US has shown a promising predictive value for the development of clinical arthritis, providing the opportunity to improve risk stratification (and disease prevention) of these individuals. The detection of inflammation on US in patients with early undifferentiated arthritis, in which a definite diagnosis cannot be reached, could predict evolution to persistent arthritis, mostly RA. This, in addition to the US potential ability to identify disease specific patterns for different rheumatic conditions, might facilitate early diagnosis and, therefore, improve the management of patients with RA, or other types of inflammatory arthritides. US has also demonstrated the capability to predict radiographic progression, and relapse risk after treatment discontinuation, in RA patients in remission according to the clinical instruments, raising implications in the management, including therapy discontinuation, of these patients. Summary US has an undeniable value in the management of patients at different stages along the RA continuum. Further research is needed to identify which groups of patients benefit the most from US imaging.

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“…There is currently no guidance or consensus on how individuals at-risk of RA should be managed. This poses a major problem for rheumatologists, who are routinely referred symptomatic anti-CCP positive individuals without synovitis from primary care practitioners (48). A recent UK survey suggests the clinical management of these patients is strikingly heterogeneous, with different disease-modifying anti-rheumatic drugs (DMARDs) often being used based solely on the clinician's judgement (48).…”

Section: Preventing Disease Progression In At-risk Individualsmentioning

confidence: 99%

Prevention and cure: The major unmet needs in the management of rheumatoid arthritis

Mankia

Matteo

Emery

2020

Journal of Autoimmunity

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The outcome of treatment of patients with rheumatoid arthritis (RA) has qualitatively improved in recent years due to better and earlier treatment approaches, and new drugs. It is now generally accepted that the phenotype of RA is the end-point of a disease continuum.Large retrospective studies have identified anti-citrullinated protein antibodies (ACPAs) and rheumatoid factor (RF) in the stored serum of patients, years before the development of clinical RA. Recent data suggest mucosal sites such as the oral mucosa (in particular the periodontium), lung and gut may be the sites where auto-immunity is initiated. The role of bacteria at these sites is reviewed. Much recent work has focussed on the role of high resolution imaging namely ultrasound (US) and magnetic resonance imaging (MRI) in identifying subclinical inflammation in at-risk individuals with early musculoskeletal symptoms (e.g. arthralgia) but without clinical synovitis. Importantly the first musculoskeletal site involved is usually not the Joint (synovium). Sub-clinical disease predicts the onset of clinical arthritis, and its timing, in symptomatic at-risk individuals. These and other predictive markers will be described. The ability to identify patients at-risk of RA, before joint involvement has led to interventions aimed at preventing/delaying disease.Once arthritis occurs, rapid remission is the target of therapy. The percentage of patients with RA achieving clinical remission has improved markedly compared with a few decades ago. The optimum outcome is to induce remission sufficiently profound so that therapy can be stopped, without flare, that is drug-free remission, which is effectively cure. Limitations of the tools used to measure remission, the outcome of tapering therapy, and new approaches 2 to achieve successful drug cessation are described. Overall, this article reviews progress towards meeting the unmet needs of prevention/cure.

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How Are Rheumatologists Managing Anticyclic Citrullinated Peptide Antibodies–positive Patients Who Do Not Have Arthritis?

Cited by 21 publications

References 5 publications

Ultrasound erosions in the feet best predict progression to inflammatory arthritis in anti-CCP positive at-risk individuals without clinical synovitis

Ultrasound erosions in the feet best predict progression to inflammatory arthritis in anti-CCP positive at-risk individuals without clinical synovitis

The Role of Musculoskeletal Ultrasound in the Rheumatoid Arthritis Continuum

Prevention and cure: The major unmet needs in the management of rheumatoid arthritis

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