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OP0264 REFINING THE PRIMARY CARE CCP+ PATIENT PATHWAY

Background 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. Objectives To assess for other factors which are associated with disease progression in patients testing CCP+ in order to optimise primary care referrals to Rheumatology. Methods 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. Results 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<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<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). Conclusion 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. References [1] Generali, et al., ACR congress 2017 [2] Nam JL, Ann Rheum Dis 2016;75:1452-1456 Acknowledgement Tracy Hulland, Harkeerat Singh, Rajvinder Cheema, Kate Smith and Borsha Sarker Disclosure of Interests 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