Anti-Cyclic Citrullinated Peptides-Negative and American College of Rheumatology Criteria-Positive. Should Disease-Modifying Anti-Rheumatic Drugs and Nonsteroidal Anti-Inflammatory Drugs Continue?

Arthur Kavanaugh, MD

Disclosures

June 05, 2006

Question

If an anti-cyclic citrullinated peptides (CCP) negative result is seen in a patient with clinically and American College of Rheumatology criteria-positive rheumatoid arthritis, is it reasonable to continue treatment with disease-modifying anti-rheumatic drugs and nonsteroidal anti-inflammatory drugs?

Dr. Nandakumar

Response from Arthur Kavanaugh, MD

There has recently been substantial and growing interest in the use of antibodies to CCP (anti-CCP) as a diagnostic test in patients with rheumatoid arthritis (RA).[1] Similar to rheumatoid factor (RF), the anti-CCP can be of value in the diagnosis of patients with RA. The present generation of anti-CCP tests has sufficient sensitivity for the diagnosis of RA that approximates that of RF, and it is more specific. Tests for RF, by definition, are positive in 5% of the general population; moreover, the prevalence of positive test results tends to increase with age, and may reach 15% or more among older persons. This is especially true of women. By contrast, although there are a few exceptions (such as psoriatic arthritis, where the prevalence of anti-CCP antibodies is about 7%), the prevalence of positive anti-CCP antibody tests in the general population is less than 5%.

In the case presented in this question, the patient is RF positive, but lacks anti-CCP antibodies. This raises an interesting issue, more relevant perhaps to the prognostic value of these tests. For many years, it has been realized that patients seropositive for RF tended to have more aggressive disease compared to those lacking RF. It appears that anti-CCP antibodies have similar prognostic relevance. In most cases, the bulk of results were concurrent for these tests (ie, either RF+ and anti-CCP+, or RF- and anti-CCP-). In the cases in which the test results are discordant, as is true here, the patient should still be considered to be seropositive in relation to therapeutic implications. This would be the case also if the patient was RF- but anti-CCP+. In cases such as this, and based on other clinical considerations, aggressive treatment to control signs and symptoms of disease would be indicated.

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