Anti-CCP antibodies as an aid to prioritization of patients referred to the rheumatology clinic.

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 rheuma-toid 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 anti-bodies, and were found to have IJD on follow-up. Ten patients were placed in category B: 8 were negative for anti-CCP antibodies and …