Diagnostic Value and Clinical Significance: DISCUSSION
The clinical course of RA is variable and its prognosis difficult to predict. In many patients, the disease process is severe and results in progressive joint destruction and serious disabilities. At all stages of RA, disease activity has a crucial role in disability. The importance of anti-CCP in both the diagnosis and the prognosis of RA has been the subject of several studies. However, there is very little information about the prevalence and the association of anti-CCP with the disease activity parameters in patients with advanced RA. Therefore, we investigated the specificity and the clinical importance of anti-CCP in advanced RA patients with a mean disease duration of 9.8 years.
It has been reported that the sensitivity of RF for RA is around 50-85%. In the present study, we found that RF was positive in 45% of the advanced RA cases. A possible explanation for the finding of a low prevalence of RF positivity in our advanced RA patients might be the intake of DMARD: most of our patients with advanced RA received DMARD during the course of their disease (Table 1). Several studies documented the level of the RF decrease with the administration of effective disease-modifying therapies. Besides that, the sensitivity of RF for RA varies, depending on the patient population and factors, such as the geographical and racial differences, may have an impact on RF positivity. It is also known that the specifity of RF is limited since RF is also found in patients with malignancy, other autoimmune and infectious diseases and to a certain extent in the healthy population. Suffer no more! Buy cialis super active online at a price you can afford.
We found that 37 out of 76 advanced RA patients (49%) were positive for anti-CCP, whereas only one (1%) of the control subjects had a positive serum for anti-CCR Diagnostic sensitivity and specificity of anti-CCP reactivity were 49.0% and 99.0%, respectively, which were similar to values reported in patients with early RA. These findings about the diagnostic value of anti-CCP in RA suggest that anti-CCP can be found in both the early and chronic RA cases with the same specificity. Furthermore, the findings of the present study confirmed that the anti-CCP is independent of the age, but RF is found more frequently in older RA patients.
Bizzaro et al. reported that anti-CCP level in RA patients was related with the duration of disease. Furthermore, Mikuls et al. noted that the reduction in anti-CCP level after a one-year RA treatment was related with both the duration of the disease and the initial anti-CCP levels. On the other hand, in this present cross-sectional study, although we could not measure the temporal changes in the levels of anti-CCP in our RA patients, we found no relation between the anti-CCP level and duration of disease. The reasons for these discrepancies are not clear and need further research. It should also be noted that these authors, in contrast to us, studied early RA in patients. cheap levitra professional
The relations between the disease activity parameters and autoantibodies directed to various cit-rulline-containing proteins in RA patients have been investigated in several studies. Vasiliauskiene et al. investigated the relations of disease activity parameters with RF, AKA, ANCA and ANA autoantibodies in RA patients with a disease duration of approximately eight years and found a significant relation between AKA and functional disability. Similarly, Mallya et al. reported that AKA had significant relations with articular index, grip strength, ESR, CRP and RF in follow-up RA patients. On the other hand, Goldbach-Mansky et al. noted that anti-Sa positivity was significantly associated with swollen joint counts and CRP levels in patients with early RA. In the present study, we investigated the relation between anti-CCP and clinical and laboratory variables in patients with advanced RA. Although both RF and anti-CCP positivities were significantly associated with duration of morning stiffness, swollen joint counts and ESR values in univariate analysis (Table 3), logistic regression has shown that only the HAQ score (functional disability) and the duration of morning stiffness were the variables significantly associated with anti-CCP positivity in patients with advanced RA (Table 4).
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The value of anti-CCP in predicting the outcome of RA has been investigated recently. Forslind et al. assessed anti-CCP in early RA patients and measured radiological joint damage and disease progression after two years of follow-up. They reported that the presence of anti-CCP at baseline was associated with significantly higher Larsen scores both at baseline and at endpoint compared to RF and other disease parameters. Kastbom et al. followed 242 patients with recent-onset RA for three years and noted that anti-CCP2 was better than RF as a predictor of the disease course. Similarly, Lindquist et al. reported anti-CCP and CRP were the only significant predictors of joint damage in RA. It was also noted that anti-CCP positivity was significantly higher in RA patients with severe than those with minimal joint destruction. In the present study, in advanced RA patients, we used the presence of rheumatoid hand deformity as an endpoint measure of the course and severity of the disease. We found that anti-CCP together with duration of disease and swollen joint count to be an important predictor of hand deformity.
The relationship among anti-CCP, joint swelling and hand deformity suggested that they might reflect a single underlying pathological process, though further work is needed to define why anti-CCP is associated with joint deformity and disease activity.
The present study had some limitations: although it was controlled, it had a relatively small number of advanced RA patients and was not a prospective one. Another limitation of the present study was that the clinical evaluation of the severity of RA-specific joint destruction was based on the joint deformity instead of radiography. However, it is also known that radiological joint damage is closely related with the clinical findings of the disease as a cumulative and irreversible indicator of structural joint destruction.
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The findings of the present study showed that anti-CCP was a specific marker in advanced RA, the prevalence, sensitivity and specificity being similar to those reported in patients with newly diagnosed RA. Additionally, anti-CCP was found to be significantly associated with some parameters of both disease activity and severity. Therefore, it might be suggested that anti-CCP might be useful in clinical practice in evaluation of both disease activity and therapeutic response in patients with advanced RA. However, further prospective studies with larger numbers of RA patients are needed to confirm the findings of the present cross sectional, case-controlled study.