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Bartonella Infection May Be Linked to Arthritis and Other Rheumatic Conditions
 A bacterium that is associated with cat scratch fever may play some role in human rheumatoid illnesses, including arthritis, according to researchers from North Carolina State University. The bacterium, named Bartonella, is transmitted predominantly by fleas, but also by ticks and other biting insects. Bartonella can also be transmitted to humans through bites or scratches from infected cats or dogs. The bacterium can be carried in cat's blood for months or years.
For study purposes, researchers tested the blood of 296 study participants looking for the Bartonella infection. The patients had previously been diagnosed with conditions such as arthritis, Lyme disease, fibromyalgia and chronic fatigue. Of the group of study participants, 62% had Bartonella antibodies (indicative of prior exposure). There was bacterial DNA found in 41% of the blood samples which allowed researchers to pinpoint the species of Bartonella. The researchers concluded that one study alone is not enough to definitively state that a subset of rheumatoid conditions is related to infection, but it does suggest a link to Bartonella in some cases and the need for further investigation.
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Photo by leroys (stock.xchng) Bartonella Infection May Be Linked to Arthritis and Other Rheumatic Conditions originally appeared on About.com Arthritis on Monday, May 14th, 2012 at 17:40:13. Permalink | Comment | Email this
Fibromyalgia Awareness Day
 Fibromyalgia is a chronic and painful condition which affects about 10 million people in the United States alone. To increase public awareness of this often misunderstood condition, May 12th is proclaimed "Fibromyalgia Awareness Day".
The condition can affect anyone, but 75% of fibromyalgia patients are women. Fibromyalgia has left many patients and physicians baffled. Years ago, not much credence was given to someone who went to the doctor with symptoms of fibromyalgia. Research has advanced our understanding of this arthritis-related condition, but there is more to learn and a need for better treatment options.
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Photo © Stockbyte / Getty Images Fibromyalgia Awareness Day originally appeared on About.com Arthritis on Saturday, May 12th, 2012 at 20:15:12. Permalink | Comment | Email this
Tofacitinib Recommended for FDA Approval to Treat Rheumatoid Arthritis
 The Arthritis Advisory Committee to the U.S. FDA has voted 8-2 to recommend approval of tofacitinib for the treatment of adult patients with moderately to severely active rheumatoid arthritis. If approved, tofacitinib would be the first new oral disease-modifying anti-rheumatic drug (DMARD) for rheumatoid arthritis in more than 10 years and the first oral biologic drug belonging to a new class of drugs known as JAK (Janus kinase) inhibitors. The FDA is expected to make their decision on Pfizer's new drug for rheumatoid arthritis in August 2012.
Unlike other currently existing biologic drugs that target extracellular entities, such as proinflammatory cytokines, tofacitinib targets intracellular pathways that operate as hubs in the inflammatory cytokine network, according to Pfizer. Tofacitinib has been studied in about 4,800 patients. There have been five Phase III trials and two ongoing, long-term extension studies in numerous countries around the world. The drug was recommended for approval despite some concern over side effects including lymphoma, infection, and elevated cholesterol levels. Proponents believe there is a need for more treatment options, especially for rheumatoid arthritis patients who have not responded to other treatments or for those who develop antibodies to current biologic treatments and have to discontinue use.
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Photo by David Sucsy (iStockphoto) Tofacitinib Recommended for FDA Approval to Treat Rheumatoid Arthritis originally appeared on About.com Arthritis on Wednesday, May 9th, 2012 at 22:50:41. Permalink | Comment | Email this
Arthritis Advisory Committee Unanimously Against Arcalyst for Gout
 The Arthritis Advisory Committee voted 11-0 against recommending FDA approval of Arcalyst (rilonacept) for the prevention of gout flares in patients starting urate-lowering treatment. Arcalyst, a drug being developed by Regeneron, is an interleukin-1 blocker. The advisory panel did not feel that benefits outweighed risks in data presented for Arcalyst. They also felt that 16 weeks, the duration of trials, was inadequate.
The committee voted 6-5 that Arcalyst is effective for treating gout flares. They also voted 8-3 that Regeneron's safety data was insufficient. The committee felt the study was too short to assess cancer risk. Regeneron studied Arcalyst on patients who were capable of taking other gout medications. It was suggested that, if patients who could not take other treatments were studied, more useful data may be produced.
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Photo by Image*After Arthritis Advisory Committee Unanimously Against Arcalyst for Gout originally appeared on About.com Arthritis on Wednesday, May 9th, 2012 at 03:41:29. Permalink | Comment | Email this
Steroids Increase Infection Risk in Children With Juvenile Idiopathic Arthritis
 Researchers from the University of Alabama at Birmingham used U.S. Medicaid data from 2000 to 2005 to compare the incidence of bacterial infection in children with and without juvenile idiopathic arthritis (JIA). It was determined that children with juvenile idiopathic arthritis have higher rates of hospitalization for bacterial infection than children without juvenile idiopathic arthritis. The risk of bacterial infection significantly increased with the use of high-dose glucocorticoids (10 mg. prednisone or more daily), but the use of methotrexate or TNF blockers was not found to increase the risk of bacterial infection among children with JIA.
Interestingly, the findings also suggested that the inflammatory or autoimmune process of JIA itself may increase the risk of infection, no matter which treatment was used. But steroids were found to double the risk of bacterial infection among JIA patients compared to those not taking steroids. When possible, avoiding steroids in JIA patients may be the preferred treatment course.
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Photo by Sheryl Griffin (iStockphoto) Steroids Increase Infection Risk in Children With Juvenile Idiopathic Arthritis originally appeared on About.com Arthritis on Saturday, May 5th, 2012 at 19:57:09. Permalink | Comment | Email this
Anxiety Nearly Twice as Common as Depression in Adults With Arthritis
 In the U.S., one-third of adults with arthritis (45 years and older) report having anxiety or depression, according to the Centers for Disease Control and Prevention (CDC). Researchers found that anxiety is nearly twice as common as depression among people with arthritis. Previous studies have revealed a connection between arthritis and depression but anxiety seems to be under-recognized and under-treated.
In the study published online April 30, 2012 in Arthritis Care & Research, out of 1,793 study participants with doctor-diagnosed arthritis or rheumatic diseases, 18% had depression and 31% had anxiety. Of those who reported having depression, 84% also had anxiety. But, only half of the participants with either depression or anxiety sought treatment during the last year. Experts suggest that screening arthritis patients for depression and anxiety may be helpful. Treating the conditions may improve quality of life.
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Photo by Natalie Souprounovich (stock.xchng) Anxiety Nearly Twice as Common as Depression in Adults With Arthritis originally appeared on About.com Arthritis on Friday, May 4th, 2012 at 18:13:02. Permalink | Comment | Email this
Laundry Tips for People With Arthritis
 Laundry isn't much fun under the best of circumstances. It's one of those tasks that has to get done eventually. People without arthritis don't really think twice about it. Well, I take that back. They may think about how long they can delay doing it. But, they don't think about laundry in the same way that people with arthritis think about it.
Physical limitations caused by arthritis make it more difficult to do laundry. Imagine adding grasping, bending, reaching, lifting, and carrying into an already painful day. We've put together some tips that will help you get the job done. Pre-planning can make a big difference. Learn more in Laundry Tips for People With Arthritis.
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Photo by Chris Gramly (iStockphoto) Laundry Tips for People With Arthritis originally appeared on About.com Arthritis on Monday, April 30th, 2012 at 22:50:07. Permalink | Comment | Email this
Obesity Linked to Increase of Rheumatoid Arthritis in Women
 Obesity is becoming more common. So is rheumatoid arthritis. Could there be a connection? According to Mayo Clinic researchers, in a study published in the April 2012 issue of Arthritis Care & Research, the answer to that question is yes -- for women.
To study the potential link between obesity and rheumatoid arthritis, Mayo Clinic researchers looked at medical records used in the Rochester Epidemiology Project. Researchers compared 813 adults with rheumatoid arthritis to 813 without. It was determined that rheumatoid arthritis cases increased by 9.2 per 100,000 women from 1985-2007. Obesity was linked to 52% of the increase.
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Photo by niknikon (iStockphoto) Obesity Linked to Increase of Rheumatoid Arthritis in Women originally appeared on About.com Arthritis on Saturday, April 28th, 2012 at 18:50:03. Permalink | Comment | Email this
Rheumatoid Arthritis Treatment - 2012 ACR Recommendations
 The American College of Rheumatology (ACR) has released recommendations for the treatment of rheumatoid arthritis. The 2012 ACR recommendations, an update of the 2008 recommendations, focuses on the use of disease-modifying anti-rheumatic drugs (DMARDs) and biologic drugs for rheumatoid arthritis.
Patients often are confused by certain issues, such as when they should start a DMARD or biologic drug, how long they should stick with a particular medication, or when they should switch to another drug. The recommendations address those and other issues. Learn more in Rheumatoid Arthritis Treatment - 2012 ACR Recommendations.
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Photo by Zhe Zhang (stock.xchng) Rheumatoid Arthritis Treatment - 2012 ACR Recommendations originally appeared on About.com Arthritis on Wednesday, April 25th, 2012 at 18:12:37. Permalink | Comment | Email this
Inflammatory Arthritis Plus Hypothroidism Increases Risk of Cardiovascular Disease
 It is known that inflammatory types of arthritis, such as rheumatoid arthritis and ankylosing spondylitis, are associated with an increased risk of cardiovascular disease. Dutch study results, published in the Annals of the Rheumatic Diseases, have revealed that inflammatory arthritis patients who also have hypothyroidism (underactive thyroid) are at even higher risk for cardiovascular disease.
Of 1,500 inflammatory arthritis patients in the study, 6.5% of women and 2.4% of men also had hypothyroidism compared to 3.9% of women and 0.8% of men without inflammatory arthritis. After adjusting for other cardiovascular risk factors, researchers found that women with both inflammatory arthritis and hypothyroidism had 3.7 times higher rate of cardiovascular disease than the control group which consisted of women with neither condition. There were not enough men with both conditions to draw a conclusion. Have you discussed your thyroid status with your doctor?
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Image © A.D.A.M. Inflammatory Arthritis Plus Hypothroidism Increases Risk of Cardiovascular Disease originally appeared on About.com Arthritis on Friday, April 20th, 2012 at 19:45:44. Permalink | Comment | Email this
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Vaccination under TNF blockade: less effective, but worthwhile
Only after biological response modifiers have become available have we begun to understand some of the complex functions of TNF in the human immune system. TNF is clearly essential for fighting intracellular pathogens, but probably not essential for fighting tumors. TNF influence on the humoral immune response, in contrast, has been more complicated to decipher, since TNF blockade is associated with both autoantibody formation and (somewhat) reduced responses to vaccination. Novel data now show that TNF is good for the humoral immune response. Vaccinations still work, however, and should be strongly recommended.
High-density lipoprotein cholesterol subfractions HDL2 and HDL3 are reduced in women with rheumatoid arthritis and may augment the cardiovascular risk of women with RA: a cross-sectional study
IntroductionHigher levels of HDL subfractions HDL3-chol and particularly HDL2-chol protect for cardiovascular disease (CVD), but inflammation reduces HDL level and may impair its anti-atherogenic effect. Changed HDL composition through the impact of inflammation on HDL subfractions may contribute to the excess risk of CVD in RA. In this study, we investigated whether HDL2-chol and HDL3-chol concentrations differ between RA patients and healthy controls, and whether these levels are related to the level of RA disease activity.
Methods:
Non-fasting blood samples were collected from 45 RA patients and 45 healthy controls. None of the participants had a history of CVD, diabetes, or used lipid-lowering drugs. HDL2-chol and HDL3-chol concentrations were obtained by ultracentrifugation. Regression modeling was used to compare HDL subfraction levels between RA patients and healthy controls, and to analyze the effect of disease activity on HDL2-chol and HDL3-chol.
Results:
HDL2-chol and HDL3-chol were significantly lower in RA patients compared to healthy controls (p=0.01, p=0.005). The HDL2:HDL3 ratio was significantly lower in patients compared to controls (p=0.04). Reduced HDL2-chol and HDL3-chol levels were primarily present in female RA patients and not in male RA patients. A modest effect of DAS28 on HDL2-chol concentrations was found, after correction for disease duration, glucocorticosteroid use and BMI, with a 0.06 mmol/L decrease with every point increase in DAS28 (p=0.05). DAS28 did not significantly affect HDL3-chol concentrations (p=0.186).
Conclusions:
Both HDL subfractions but particularly HDL2-chol concentrations were decreased in RA, primarily in women. This seems to be associated with disease activity and is of clinical relevance. The reduction of the HDL subfraction concentrations, particularly the supposedly beneficial HDL2-chol, may negatively impact the cardiovascular risk profile of women with RA.
Body mass index influences the response to infliximab in ankylosing spondylitis
IntroductionThe excess of adipose tissue in obese individuals may have immunomodulating properties and pharmacokinetic consequences. The aim of this study was to determine whether body mass index (BMI) affects response to infliximab (IFX) in ankylosing spondylitis (AS) patients.
Methods:
In 155 patients retrospectively included with active AS, the BMI was calculated before initiation of IFX treatment (5 mg/kg intravenously). After 6 months of treatment, changes from baseline in BASDAI, Visual Analogue Scale (VAS) pain, C-reactive protein (CRP) level and total dose of Nonsteroidal anti-inflammatory drug (NSAID) was dichotomized with a threshold corresponding to a decrease of 50% of initial level of the measure, into binary variables assessing response to IFX (BASDAI50, VAS50, CRP50, NSAID50). Whether BMI was predictive of response to IFX therapy according to these definitions was assessed with logistic regression.
Results:
Multivariate analysis found a higher BMI was associated with a lower response for BASDAI50 (P=0.0003, OR 0.87 95%CI0.81-0.94VAS50 (P<0.0001, OR 0.87 95%CI[0.80-0.93]), CRP50 (P=0.0279, OR 0.93 95%CI0.88-0.99) and NSAID50 (P=0.0077, OR 0.91 95%CI0.85-0.97criteria. According to the 3 WHO BMI categories, similar results were found for BASDAI50 (77.6%, 48.9% and 26.5%, P<0.0001), VAS50 (72.6%, 40.4% and 16.7%, P<0.0001), CRP50 (87.5%, 65.7% and 38.5%, P=0.0001) and NSAID50 (63.2%, 51.5% and 34.6%, P=0.06).
Conclusions:
This study provides the first evidence that a high BMI negatively influences the response to IFX in AS. Further prospective studies, including assessment of the fat mass, pharmacokinetics and adipokines dosages are mandatory to elucidate the role of obesity in AS IFX response.
Elevated levels of fibrinogen-derived endogenous citrullinated peptides in synovial fluid of rheumatoid arthritis patients
IntroductionRheumatoid arthritis (RA) is an autoimmune disease characterized by inflammation of the joints and the presence of autoantibodies directed against proteins containing the non-standard arginine-derived amino acid citrulline. The protein fibrinogen, which has an essential role in blood clotting, is one of the most prominent citrullinated autoantigens in RA, particularly because it can be found in the inflamed tissue of affected joints. Here, we set out to analyze the presence of citrullinated endogenous peptides in the synovial fluid of RA and arthritic control patients.
Methods:
Endogenous peptides were isolated from the synovial fluid of RA patients and controls by filtration and solid phase extraction. The peptides were identified and quantified using high resolution liquid chromatography-mass spectrometry.
Results:
Our data reveal that the synovial fluid of RA patients contains soluble endogenous peptides derived from fibrinogen, containing significant amounts of citrulline residues and in some cases also phosphorylated serine. Several citrullinated peptides are found to be more abundantly present in the synovial fluid of RA patients compared to patients suffering from other inflammatory diseases affecting the joints.
Conclusions:
The increased presence of citrullinated peptides in RA patients points towards a possible specific role of these peptides in the immune response at the basis of the recognition of citrullinated peptides and proteins by RA patient autoantibodies.
Increased type II collagen cleavage by cathepsin K and collagenase activities with aging and osteoarthritis in human articular cartilage
IntroductionThe intra-helical cleavage of type II collagen by proteases including collagenases and cathepsin K is increased with aging and osteoarthritis (OA) in cartilage as determined by immunochemical assays. The distinct sites of collagen cleavage generated by collagenases and cathepsin K in healthy and OA human femoral condylar cartilages were identified and compared.
Methods:
Fixed frozen cartilage sections were examined immunohistochemically, using antibodies that react with the collagenase-generated cleavage neoepitopes, C2C and C1,2C, and the primary cleavage neoepitope (C2K) generated in type II collagen by the action of cathepsin K and possibly by other proteases but not by any collagenases studied to date.
Results:
In most cases the staining patterns for collagen cleavage were similar for all three epitopes: weak to moderate mainly pericellular staining in non-OA cartilage from younger individuals and stronger, more widespread staining in ageing and OA cartilages that often extended from the superficial to the mid/deep zone of the tissue. In very degenerate OA specimens, with significant disruption of the articular surface, staining was distributed throughout most of the cartilage matrix.
Conclusions:
Cleavage of collagen by proteases usually arises pericellularly around chondrocytes at and near the articular surface, subsequently becoming more intense and extending progressively deeper into the cartilage with ageing and OA. The close correspondence between the distributions of these products suggests that both collagenases and cathepsin K, and other proteases that may generate this distinct cathepsin K cleavage site, are usually active in the same sites in the degradation of type II collagen.
Low-dose oral prednisone improves clinical and ultrasonographic remission rates in early rheumatoid arthritis. Results of a 12 month open-label randomized study.
IntroductionIn early rheumatoid arthritis (RA), low-dose oral prednisone (PDN) co-medication yields better clinical results than monotherapy with disease modifying antirheumatic drugs (DMARDs). In addition, ultrasonographic (US) evaluation reveals rapid and significative effects of glucocorticosteroids on subclinical synovitis. No data currently exists which examines the clinical and US results offered by GC co-medication over DMARD monotherapy in early RA patients.
Methods:
Two hundred and twenty (220) patients with early RA (<1 year from clinical onset) were treated according to a low disease activity (LDA) targeted step-up protocol including methotrexate (MTX) and, in the active treatment arm, low-dose (6.25 mg/d) oral PDN over 12 months. Clinical disease activity measures were collected at baseline, 2, 4, 6, 9 and 12 months, and US examination of hands was performed at baseline, 6 and 12 months. Grey-scale (GS) and power Doppler (PD) synovitis were scored (0 to 3) for each joint. At 12 months, clinical remission, according to disease activity score 28 (DAS28), was defined as clinical outcome, and total joint PD score=0 (PD negativity) as imaging outcome.
Results:
Each group included 110 patients with comparable demographic, clinical, laboratory and US characteristics. At 12 months, LDA rate was similar in the 2 groups, whilst clinical remission rate (RR 1.61 [95%CI 1.08, 2.04]) and PD negativity rate (RR 1.31 [95%CI 1.04, 1.64]) were significantly higher in MTX+PDN group.
Conclusions:
In early RA, despite a similar response rate in terms of LDA, low-dose oral PDN co-medication led to a higher proportion of clinical remission and PD negativity compared to MTX monotherapy, thus ensuring a better disease activity control.Trial Registration: Current Controlled Trials ISRCTN2486111
Resistin in idiopathic inflammatory myopathies
IntroductionTo evaluate and compare the serum levels and local expression of resistin in patients with idiopathic inflammatory myopathies to controls, and to determine the relationship between resistin levels, inflammation and disease activity.
Methods:
Serum resistin levels were determined in 42 patients with inflammatory myopathies and 27 healthy controls. The association between resistin levels, inflammation, global disease activity and muscle strength was examined. The expression of resistin in muscle tissues from patients with inflammatory myopathies and healthy controls was evaluated. Gene expression and protein release from resistin-stimulated muscle and mononuclear cells were assessed.
Results:
In patients with inflammatory myopathies, the serum levels of resistin were significantly higher than those observed in controls (8.53+/-6.84 vs. 4.54+/-1.08 ng/ml, P<0.0001) and correlated with CRP levels (r=0.328, P=0.044) and global disease activity score MYOACT (r=0.382, P=0.026). Stronger association was observed between the levels of serum resistin and C-reactive protein (CRP) levels (r=0.717, P=0.037) as well as myositis disease activity assessment visual analogue scales (MYOACT; r=0.798, P=0.007), and there was a trend towards correlation between serum resistin and myoglobin levels (r=0.650, P=0.067) in anti-Jo-1 positive patients. Furthermore, in patients with DM, serum resistin levels significantly correlated with MYOACT (r=0.667, P=0.001), creatine kinase (r=0.739, P=0.001) and myoglobin levels (r=0.791, P=0.0003) and showed a trend towards correlation with CRP levels (r=0.447, P=0.067). Resistin expression in muscle tissue was significantly higher in patients with inflammatory myopathies compared to controls, and resistin induced the expression of interleukins (IL)-1beta and IL-6 and monocyte chemoattractant protein (MCP)-1 in mononuclear cells but not in myocytes.
Conclusions:
The results of this study indicate that higher levels of serum resistin are associated with inflammation, higher global disease activity index and muscle injury in patients with myositis-specific anti-Jo-1 antibody and patients with dermatomyositis. Furthermore, up-regulation of resistin in muscle tissue and resistin-induced synthesis of pro-inflammatory cytokines in mononuclear cells suggest a potential role for resistin in the pathogenesis of inflammatory myopathies.
Nothing lasts forever - a critical look at sustained remission
Remission is key to prevent progression of rheumatoid arthritis, but it is still rarely seen in clinical practice, not to speak of sustained remission, which is the best possible disease outcome of rheumatoid arthritis. New strategies and recommendations focus on achievement of remission, but it is unclear how long remission can actually be maintained in clinical practice. A study by Prince and colleagues gives insights into this question, and raises some other questions for the future.
Mycophenolic acid counteracts B cell proliferation and plasmablast formation in patients with systemic lupus erythematosus
IntroductionClinical trials revealed a high efficacy of mycophenolate mofetil (MMF) in inducing and maintaining remission in patients with class III-V-lupus nephritis. Also extrarenal manifestations respond to MMF treatment. However, few attempts have been undertaken to delineate its mechanism of action in systemic lupus erythematosus (SLE) a disease characterized by enhanced B cell activation.
Methods:
Clinical and paraclinical parameters of 107 patients with SLE were recorded consecutively and analyzed retrospectively. Patients were divided into treatment groups (MMF: n=39, azathioprine (AZA) n=30 and controls without immunosuppressive therapy n=38). To further delineate the effect of mycophenolic acid (MPA) on naive and memory B cells in vitro assays were performed.
Results:
Although patients taking AZA flared more frequently than patients on MMF or controls, the analysis of clinical parameters did not reveal significant differences. However, profound differences in paraclinical parameters were found. B cell frequencies and numbers were significantly higher in patients taking MMF compared to those on AZA but lower numbers and frequencies of plasmablasts were detected compared to AZA-treated patients or controls. Notably, MMF treatment was associated with a significantly higher frequency and number of transitional B cells as well as naive B cells compared to AZA treatment. Differences in T cell subsets were not significant. MPA abrogated in vitro proliferation of purified B cells completely but had only moderate impact on B cell survival.
Conclusions:
The thorough inhibition of B cell activation and plasma cell formation by MMF might explain the favorable outcomes of previous clinical trials in patients with SLE, since enhanced B cell proliferation is a hallmark of this disease.
Long-term stability of anti-cyclic citrullinated peptide antibody status in patients with early inflammatory polyarthritis
IntroductionThe utility of reassessing anti-cyclic citrullinated peptide (anti-CCP) antibody status later in disease in patients presenting with early undifferentiated inflammatory polyarthritis, particularly in those who test negative for both anti-CCP and rheumatoid factor (RF) at baseline, remains unclear. We aimed therefore to determine the stability of CCP antibody status over time and the prognostic utility of repeat testing in subjects with early inflammatory polyarthritis (IP).
Methods:
Anti-CCP and RF were measured at baseline and 5 years in 640 IP patients from the Norfolk Arthritis Register, a primary care based inception cohort. The relationship between change in anti-CCP status/titre and the presence of radiological erosions, the extent of the Larsen score and Health Assessment Questionnaire (HAQ) score by 5 years was investigated.
Results:
Using a cut-off of 5 U/ml, 28% subjects tested positive for anti-CCP antibodies, 29% for RF and 21% for both at baseline. Nine (2%) anti-CCP negative patients seroconverted to positive and 9 (4.6%) anti-CCP positive individuals became negative between baseline and 5 years. In contrast, RF status changed in 17% of subjects. However, change in RF status was strongly linked to baseline anti-CCP status and was not independently associated with outcome. Ever positivity for anti-CCP antibodies by 5 years did not improve prediction of radiographic damage compared to baseline status alone (accuracy 75% vs 74%). A higher baseline anti-CCP titre (but not change in anti-CCP titre) predicted worse radiological damage at 5 years (P <0.0001), even at levels below the cut-off for anti-CCP positivity. Thus, a titre of 2-5U/ml was strongly associated with erosions by 5 years (odds ratio 3.6 (1.5,8.3); P = 0.003).
Conclusions:
Repeat testing of anti-CCP antibodies or RF in patients with IP does not improve prognostic value and should not be recommended in routine clinical practice.
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