Journal club presentation

Presenter: Dr Spoorthy
Chair person: Dr Prabhakar
Antibodies to cyclic citrullinated
protein and erythrocyte
sedimentation rate
predict hand bone loss in
patients with rheumatoid
arthritis of short duration: a
longitudinal study
Journal: Arthritis Research &
 Rheumatoid arthritis
• Rheumatoid arthritis (RA) is a chronic
multisystem disease
• characteristic feature- persistent inflammatory
synovitis, usually involving peripheral joints in a
symmetric distribution.
• hallmark of the disease -synovial inflammation ,
cartilage damage and bone erosions ,
subsequent changes in joint integrity.
 Epidemiology

• Most common autoimmune disease

• Affects ~1%(0.8) of the world’s population
• In pt’s <60… 3-5:1 female predominance
• 4th 5th decade.. 80% betwn -35y-50y
• genetic predisposition- HLA-DR4 (DR 1*0401 ) This
association is particularly strong for individuals who
develop RA associated with antibodies to cyclic
citrullinated polypeptides (CCP).
 ETIOLOGY
• Unknown
• Response to infectious agents in a
genetically suscetible host
• mycoplasma,cmv, parvo, rubella
 pathogenesis
• Microvascular injury , increase in synovial lining
cells
• Autoimmune inflammatory destruction of the synovium
• AKA – pannus
– A proliferative mass of inflammatory vascularized tissue

• Can erode into bone and cartilage

• Aided by local generation of metalloproteinases
• As the process continues, the synovium becomes
edematous and protrudes into the joint cavity as villous
projections.
• cytokines IL-1 and TNF play an important role by
stimulating the cells of the pannus to produce
collagenase and other neutral proteases
 Pathogenesis
• The inflammation in RA causes a shift in
the bone metabolism towards increased
osteoclast mediated bone turn-over
 RA Classification criteria – 1987
American College of Rheumatology
1. Morning stiffness in and around the joints lasting at least 1
hour
2. At least 3 joint areas simultaneously have had soft tissue
swelling or fluid (PIP, MCP, wrist, elbow, knee, ankle, and
MTP)
3. At least 1 area swollen (as defined above) in a wrist, MCP,
or PIP joint
4. Symmetical involvement of the same joint areas (as defined
in 2)
5. Subcutaneous nodules over bony prominences, extensor
surfaces, or in juxta-articular regions
6. Postive serum Rheumatoid Factor
7. Radiographic changes typical of rheumatoid arthritis on
hand and wrist radiographs (must include erosions or
unequivocal bony decalcification)
Need 4 of 7 for Diagnosis
 Characteristic changes of the hand
include
• (1)
radial deviation at the wrist with ulnar deviation of the
digits, often with palmar subluxation of the proximal
phalanges ("Z" deformity)
• (2) hyperextension of the proximal interphalangeal joints,
with compensatory flexion of the distal interphalangeal
joints (swan-neck deformity)
• (3) flexion contracture of the proximal interphalangeal
joints and extension of the distal interphalangeal joints
(boutonnière deformity);
• (4) hyperextension of the first interphalangeal joint and
flexion of the first metacarpophalangeal joint with a
consequent loss of thumb mobility and pinch.
 Imaging Techniques
• X-Rays -Measurements of localised bone
involvement in RA can be performed by digital
X-ray radiogrammetry (DXR), which gives an
estimate of cortical hand bone mineral density
(DXR-BMD)
• Dexa Scans- dual energy x-ray absorptiometry, may be useful in
detecting early bone loss in rheumatoid arthritis (2 - 27 months after onset).
• Ultrasound. power Doppler ultrasonography (PDUS) or
quantitative ultrasound (QUS). PDUS -monitoring inflammatory
activity in the joint. QUS, which is used for osteoporosis, can detect
bone loss in fingers, a good indicator of early RA.
 The inflammation in RA causes a shift in
the bone metabolism towards
increased osteoclast mediated bone turn-
over.
• The dysregulation causes reduced bone
mass which is known as an early feature
in RA patients, visualised as juxta-
articular bone demineralisation on
radiographs.
• Quantification of this localised bone loss
has been proposed as an outcome
measure in early RA.
 Laboratory tests
• Acute phase reactants:ESR & CRP
• Autoantibodies:RF (usually IgM)
• ANA
• Anti-CCP (cyclic citrullinated peptide)
• Anaemia: normocytic normochromic
 Rheumatoid Factor (RF)
• RF test is
approximately 65%-
75% sensitive for the
diagnosis

• The presence of RF,

even in high titers or
large amounts, is not
specific for RA
 Conditions Assoc. with (+) Tests
for Rheumatoid Factor
• Rheumatologic Diseases
• Rheumatoid arthritis (~70%)
• Sjögren’s syndrome (~90%)
• Lupus (~20%)
• Cryoglobulinemia syndrome (90%)

• Lung Diseases
• Interstitial fibrosis
• Silicosis

• Infections
• Hepatitis C virus
• Acute viral infections
• Endocarditis
• Tuberculosis

• Miscellaneous
• Sarcoidosis
• Malignancies
• Aging
 Anti-CCP
• There are other RA-associated auto-Abs
known to be specific for rheumatoid arthritis
– Perinuclear factor
– Antikeratin antibodies

• They are not widely used due to technical

difficulties with their detection
 Anti-CCP
• The epitopes of the antigens (target of
Ab’s) are arginyl residues

• These are converted “citrullinated” by an

enzyme to citrulline (an amino acid). The
enzyme is called PAD14.

• These citrullinated epitopes are

recognized by other RA-assoc. Ab’s
 Anti-CCP
• Citrullinated peptides have been
synthesized as Ag’s for diagnostic
immunoassays

• ELISA
– Wells coated w/ cyclic citrullinated peptides
– Exposed to RA pt’s serum
– Colorimetric response in Ag-Ab binding
 Anti-CCP
• Anti-CCP antibodies are locally produced
in inflamed joints
• Anti-CCP antibody is present before
symptoms develop, therefore,
• Frequently (+) early in the course of RA
when the diagnosis may be uncertain.
• Unlike RF, anti-CCP is not associated with
Hep C infection
 Prognosis
• Presence of CCP antibodies is associated
with development of erosive arthritis.

• The presence of anti-CCP in high titer has

important prognostic implications

• Anti-CCP helps in predicting which RA

patients will have persistent disease, and
erosive disease
 Features correlated with a greater
likelihood of developing joint
abnormalities or disabilities
• >20 inflamed joints,
• a markedly elevated ESR,
• radiographic evidence of bone erosions
• rheumatoid nodules,
• high titers of serum rheumatoid factor
• anti-CCP antibodies
• the presence of functional disability
• advanced age at onset,
 contd
• the presence of comorbid conditions,
• low socioeconomic status or educational
level,
• the presence of HLA-DR 1*0401 or -DR
*0404.
 Algorithm for the medical
management of rheumatoid arthritis
 Introduction of the study
• Disease course of RA is heterogeneous and
about one third of RA patients do not experience
joint damage.
• Early intervention with disease-modifying antirheumatic drugs
(DMARDs) which inhibit joint damage, is accepted as a cornerstone
in the treatment strategy of RA
• The identification of patients prone to bone
involvement is important at an early stage of the
disease in order to individually tailor the RA
treatment and optimise disease outcome
 objective
• A longitudinal study to examine if
serological markers also predict hand
bone mineral density (BMD) loss in
patients with RA of short disease duration.
 Methods
• 163 patients with RA of short disease
duration (2.4 years) were included and
followed longitudinally.
• Antibodies to cyclic citrullinated protein
(anti-CCP), rheumatoid factor (RF),
erythrocyte sedimentation rate (ESR), and
C-reactive protein (CRP) were analysed
from baseline blood-samples.
•
 CONTD.
• Hand BMD was measured by digital X-ray
radiogrammetry (DXR) based on hand
and wrist radiographs obtained at
baseline and 1, 2 and 5-year follow-up.
 EURIDISS (European Research on
Incapacitating Disease and Social Support)
study, a Norwegian arm of the cohort was
followed longitudinally. At inclusion in
1992,238
patients aged from 20 to 70 years, with a
clinical diagnosis of RA and disease duration
of less
than 4 years were included . out of these 163
were included in the cohort.
 Baseline assessment
• Blood samples
• Medical history
• health assessment questionnaire (HAQ).
• conventional, bilateral hand and
• wrist radiographs were taken at baseline
and one, two and five-year follow-up
 Treatment given
• The percentages of patients who were
treated with DMARDs/ prednisolone at
• baseline 53.8/26.3
• one 46.9/28.1
• two 50.6/29.4
• Five 54.9/37.5,
 Lab analysis used
• Crp
• Esr
• Anti ccp- . Values above 25 U/ml were
considered positive
• IgA and IgM rheumatoid factor (RF)-
ELISA technique, positive cut-off at 25
U/ml
• BMD was measured by DXR
• The DXR software automatically
recognises the regions of
interest(metacarps two to four) and
measures the cortical thickness, bone
width, and bone porosity118 times per
cm..
 Statistical analysis
• Dxr-bmd changes calculated as a percentage
difference betwn follow up and baseline..
• Prediction of Loss in cortical hand bone was
defined as a negative change in DXR-BMD
exceeding the LSC.
• Least significant change being 0.79% individual
differences from baseline to one yr, one to two
and two to five yrs..
• This correlated with clinical cutoffs of increased
values of serological markers .
 Statistical analysis. Contd..
ESR • >20MM/HR
CRP • >10MG/DL
IGA RF • >25U/ML
IGM RF • >25U/ML
ANTI-CCP • >25U/ML

Associations were explored by

linear regression analysis
and multivariate regression analysis
 Results-% of patients with loss
in cortical bone loss
At one yr of follow up 66.7%

At second yr 77.3%

At fifth yr 89.1%
 Change in DXR-BMD
YOUNGER OLDER
• 1 TO 2 YRS – WOMEN(<4 WOMEN
• 0YRS)
-1.46%
1YR-
• 2 TO 5YRS- -2.32 -1.15
• -3.81% 2YR-
-3.39 -1.73
5YR-
-7.45 -3.88
 Associations between baseline
serological biomarkers and Change
in DXR-BMD(ODDS RATIO)
1YR 2YR 5 YR
ANTI CCP>25 2.2 2.6 4.9

ESR 4.5 3.5

REDNISOLO 4.7
NE USE
AGE 1 1 1.1
SEX-FEMALE 1 0.5 0.9
 RESULTS CONTD..
• Anti-CCP was a consistent and independent
predictor of cortical hand bone loss during the
five-year follow-up period in multivariate logistic
regression analyses.
• Elevated baseline ESR was independently
predictive of one- and two-year cortical hand
bone loss.
• Two-year cortical hand bone loss was also
predicted by prednisolone use
 Weaknesses of the study
• A lack of available data on important factors that
influence the bone mineral density. There were
no available data on use of vitamin-D, calcium
supplements, hormone replacement therapy or
anti-resorptive treatment.
• There were no available specifications on the
different DMARDs used during the five-year
period.
• The menopausal status of the patients was not
known.
 Weakness contd…
• Another weakness of this study was that
DXA-BMD measurements were not
performed.
• The observed cortical bone loss could
neither be validated against the measured
gold standard DXA-BMD,
• Nor could the observed predictors be
validated against trabecular bone loss.
 CONCLUSIONS
• In this study THEY confirm that RF and
CRP are associated with DXR-BMD.
• In addition they show that elevated levels
of anti-CCP and ESR are independent
predictors of DXR-BMD loss.
• These common predictors support that
erosions and focal bone loss have a
common cellular mechanism.
 conclusions
• The results of these analyses implies that
a hypothetical forty year old female RA
patient with
• elevated levels of ESR and anti-CCP
would at one-year follow-up have a
predicted DXRBMD loss of 4.2% and
• an odds of 6.4 for cortical hand bone loss,
compared to a similar patient with normal
levels of ESR and anti-CCP
• findings support that elevated levels of anti-CCP
and ESR are important markers that have
potential impact on the disease course and
should have impact on considerations about
treatment strategies in RA patients.
• Further, this observation adds support to the
hypothesis of similar mechanisms being involved
in hand bone loss and erosive disease.
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• The association of anti-CCP antibodies with disease activity in
rheumatoid arthritis
• Münevver Serdaroğlu, 1 Haşim Çakırbay,1 Orhan Değer,2 Sevil
Cengiz,2 and Sibel Kul3
• 1Physical Therapy and Rehabilitation, Karadeniz Technical
University, Trabzon, Turkey
• 2Biochemistry Department, Karadeniz Technical University,
Trabzon, Turkey
• 3Radiology Department, Karadeniz Technical University, Trabzon,
Turkey
• Münevver Serdaroğlu, Phone: +90-462-3775426, Fax: +90-505-
4828581, Email: drmunser@yahoo.com.
• Corresponding author.
• Received July 17, 2007; Accepted March 16, 2008.