Tools for Practice Outils pour la pratique


#146 Anti-CCP: A truly helpful Rheumatoid Arthritis lab test?


CLINICAL QUESTION
QUESTION CLINIQUE
For Adult Rheumatoid Arthritis (RA), what is the diagnostic utility of Anti-Cyclic Citrullinated Protein antibodies (Anti-CCP)?


BOTTOM LINE
RÉSULTAT FINAL
Anti-CCP, with ~96% specificity and ~14 positive likelihood ratio, is good for assisting with the diagnosis of RA. Anti-CCP is present in only ¼ to ½ of patients before or at diagnosis, so a negative test does NOT rule out RAIt can also predict more aggressive joint erosion.  



CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session



EVIDENCE
DONNÉES PROBANTES
  • Seven systematic reviews1-7 of Anti-CCP in adult RA, with 27-151 observational studies. Pooled results: 
    • Sensitivity and specificity2-4,7 were 53%-71% and 95-96%, respectively. 
    • Likelihood ratios:3,4 Positive likelihood ratio 12.5-15.9 and negative 0.36-0.42. 
    • Focusing on higher-level studies (diagnostic cohort) with an undifferentiated arthritis presentation: sensitivity generally lower (~54%) but specificity similar.4 
  • Interpretation: Positive Anti-CCP means RA likely but a negative does NOT rule out RA. 
  • Concerns (although study quality did not seem to impact findings7): 
    • Minority of studies well-designed: Cohorts of early, undifferentiated patients with prolonged follow-up by blinded study personnel.4   
    • Significant heterogeneity: Different control population,4 study designs,4 test cut-offs,2,6 and laboratory standardizations.2,6  
Context:   
  • Positive Anti-CCP also predicts joint erosion in RA, Odds Ratio 4.4 (95% Confidence Interval 3.6-5.3).8 
  • How common is Anti-CCP: 
    • In RA patients?2 
      • 23% early in symptoms.   
      • ~50% at diagnosis. 
      • ~53-70% at two years after diagnosis.  
    • Other populations?2 
      • ≤1.5% in healthy populations. 
      • ≤10% in other rheumatic disease (from lupus to psoriatic arthritis), except palindromic which is similar to RA.   
        • Perhaps higher in some if erosive joint disease present.9  
  • Rheumatoid Factor has a similar sensitivity but worse specificity.3 
    • SpecificityAnti-CCP=95% and Rheumatoid Factor=85%. 
      • Positive likelihood ratios are 12.5 versus 4.9, respectively. 
    • Interpretation: Positive Anti-CCP > positive Rheumatoid Factor for making an RA diagnosis. 
  • In Juvenile RA, Anti-CCP has a similar specificity (99%) but considerably worse sensitivity (10%): Anti-CCP is commonly negative, which does not rule out RA.10   
  • RA diagnostic criteria: As well as joint involvement and acute phase reactants (ESR or C-Reactive Protein), Anti-CCP and Rheumatoid Factor are RA serology markers.11   
    • Note: Anti-CCP is sometimes called ACPA (Anti-Citrullinated Protein Antibody). 


Latest Tools for Practice
Derniers outils pour la pratique

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females

How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?
Read Lire 0.25 credits available Crédits disponibles

#361 Preventing RSV Infections in Infants

How safe and effective are monoclonal antibodies to prevent respiratory syncytial virus (RSV) infections in infants?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session


Author(s)
Auteur(s)
  • Emelie Braschi PhD MD
  • G. Michael Allan MD CCFP

1. Riedemann JP, Muñoz S, Kavanaugh A. Clin Exp Rheumatol. 2005; 23(5 Suppl 39):S69-76.

2. Avouac J, Gossec L, Dougados M. Ann Rheum Dis. 2006; 65:845-51.

3. Nishimura K, Sugiyama D, Kogata Y, et al. Ann Intern Med. 2007; 146:797-808.

4. Whiting PF, Smidt N, Sterne JA, et al. Ann Intern Med. 2010; 152:456-64; W155-66.

5. Schoels M, Bombardier C, Aletaha D. J Rheumatol Suppl. 2011; 87:20-5.

6. Taylor P, Gartemann J, Hsieh J, et al. Autoimmune Dis. 2011;2011:815038.

7. Zintzaras E, Papathanasiou AA, Ziogas DC, et al. BMC Musculoskelet Disord. 2012; 13:113.

8. Jilani AA, Mackworth-Young CG. Int J Rheumatol. 2015; 2015:728610.

9. Budhram A, Chu R, Rusta-Sallehy S, et al. Lupus. 2014; 23(11):1156-63.

10. Wang Y, Pei F, Wang X, et al. J Immunol Res. 2015; 2015:915276.

11. Aletaha D, Neogi T, Silman AJ, et al. Arthritis Rheum. 2010; 62:2569-81.

Authors do not have any conflicts to disclose