OP0264 REFINING THE PRIMARY CARE CCP+ PATIENT PATHWAY
Authors: Leticia Garcia-Montoya, Jacqueline Nam, Kulveer Mankia, Laurence Duquenne, Peta Pentony, Andrea Dimatteo, Paul Emery
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> It is known that the presence of anti-CCP antibodies (CCP+) is associated with the development of rheumatoid arthritis (RA). Between 0-9% of the general population test positive [1], but only a small percentage of them will develop the disease. Previous work [2] showed that the selection of individuals with non-specific musculoskeletal symptoms, without clinical synovitis enriched the prevalence of anti-CCP positivity and also the likelihood of imminent progression to inflammatory arthritis. <h3>Objectives</h3> To assess for other factors which are associated with disease progression in patients testing CCP+ in order to optimise primary care referrals to Rheumatology. <h3>Methods</h3> A prospective observational study recruiting patients over 18 years old with a new musculoskeletal complaint and no clinical synovitis was conducted. Patients were recruited from primary care centres across the UK from July 2007 until February 2018. Those testing CCP+ in anti-CCP2 assay (immunocap method, Phadia assay) were invited to come to Leeds for assessment and follow-up including a baseline musculoskeletal ultrasound. Patients unable to attend were sent questionnaires 12 months later and were contacted in January 2019 to assess their status. <h3>Results</h3> 5702 eligible patients were recruited from primary care. 2.99% (171/5702) patients tested CCP+ and data from 150 patients was available for analysis: 42.7% (64/150) progressed to inflammatory arthritis (IA), predominantly RA. The mean time of progression was 242 days and 91% progressed in less than 12 months. The absence of pain in the hands or feet had a negative predictive value of 91% for the development of IA (p=0.001) (fig.1); indeed, the RR for progression to IA in patients with a new complaint in hands or feet was 1.6 (95% CI 1.02-2.36, p=0.025). Regarding the presence of antibodies, CCP+ high titre patients had a RR of 2.1(95% CI 1.63-2.68, p&lt;0.001) for the development of IA and 93% of all progressors were CCP+ high titre. Only 9% (4/43) of patients with CCP+ low titre progressed to IA vs the 57% (55/97) of patients with CCP+ high titre (p&lt;0.001). All low titre progressors had pain in hands and feet and history of smoking exposure. 114 patients came to secondary care for assessment and a baseline musculoskeletal ultrasound scan was performed in 72 of them: the presence of PD in hands/feet was associated with progression to IA with a RR 2.4 (95%CI 1.27-4.58, p=0.01). <h3>Conclusion</h3> CCP+ patients without clinical synovitis who do not have pain in the hands or feet are unlikely to progress to IA especially if they have low titre antibodies. A high anti-CCP titre, new pain in hands/feet and PD in these joints are associated with rapid progression. These data may help optimise the primary care referrals to Rheumatology. <h3>References</h3> [1] Generali, et al., ACR congress 2017 [2] Nam JL, Ann Rheum Dis 2016;75:1452-1456 <h3>Acknowledgement</h3> Tracy Hulland, Harkeerat Singh, Rajvinder Cheema, Kate Smith and Borsha Sarker <h3>Disclosure of Interests</h3> Leticia Garcia-Montoya: None declared, Jacqueline Nam: None declared, Kulveer Mankia Grant/research support from: Research support from BMS and Lilly, Speakers bureau: Honoraria from Abbvie, UCB, Laurence Duquenne: None declared, Peta Pentony: None declared, Andrea DiMatteo: None declared, Paul Emery Grant/research support from: Pfizer, MSD, AbbVie, Bristol-Myers Squibb, Roche, Consultant for: Pfizer, MSD, AbbVie, Bristol-Myers Squibb, UCB, Roche, Novartis, Gilead,Samsung, Sandoz and Lilly