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ERA Rx is delayed for different reasons depending on RF/ACPA status

Dr. Janet Pope  Featured
November 8 2015 6:10 PM ET via RheumReports RheumReports

Pratt et al studied 173 RA referrals over 2.5 years in one practice (Abstract #447). Half the referrals were positive for both RF and ACPA; 1/3 were double negative, and approximately 10% positive for RF alone and 10% for ACPA alone. They found that if the patient was double seropositive, there were longer delays for patients to see their primary care doctor, whereas if both RF and ACPA were negative, the delay in DMARD treatment was due to the rheumatologist not treating as quickly. It makes sense that positive tests are a trigger for ordering a referral (Dr. Andy Thompson found that with his CART [Canadian Arthritis Referral Tool]). It also is likely that a seronegative patient needs longer for a rheumatologist to rule out other diseases before considering the patient has RA (and if using the 2010 RA criteria, seronegative patients have less ability to be classified as RA if joint counts are equal in a seropositive vs seronegative patient).

I wonder if there is a totally different reason – maybe acute onset RA is different? It presents quickly and gets treated, whereas double seropositive patients perhaps smolder or are palindromic for longer (and maybe it takes longer to develop both antibodies, but studies show that in many patients, RF and ACPA have been present for years prior to a diagnosis of RA). If this hypothesis is true, then it should be that acute onset patients are more likely to be seronegative. This study did not address this subset, but in the CATCH (Canadian early arthritis cohort), the elderly had higher disease activity, more seronegative serology and shorter disease duration when they presented, so the theory holds up.

I will now make an opinion not based on any data. It is likely that the patient with RA is referred if they have obvious swollen joint(s) or a positive test (RF, ACPA, high inflammatory marker, X-ray abnormality). Without this, a referral is delayed, whereas if a GP sees significant swelling, they may start steroids and when seen by a rheumatologist, there is uncertainty if the patient has a self-limited arthritis without positive serology. I actually use initiation of steroids by the GP as a trigger to see someone quickly.


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About the Author

Dr. Janet Pope
Dr. Janet Pope

Dr. Janet Pope is Professor of Medicine at Western University and Division Head of Rheumatology. Dr. Pope's research interests include epidemiologic studies in scleroderma, classification criteria in systemic sclerosis, systemic lupus erythematosus and rheumatoid arthritis.

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