For early RA with positive ACPA, clinical treatment should not be taken lightly!

*It is only for medical professionals to read for reference.
Take precautions and prevent risks early! Rheumatoid arthritis (RA) is a common clinical chronic progressive disease.
The early onset is highly insidious and difficult to attract attention.
In addition to small joint swelling and pain, it can also be accompanied by non-specific systemic symptoms (such as low fever and fatigue)
.

If it is not treated early, as the course of the disease is prolonged, joint swelling and pain will gradually evolve into joint destruction, causing serious damage to the patient's normal movement function
.

Early recognition and treatment of RA can increase the rate of treatment compliance and prevent the progress of invasive lesions
.

The occurrence of RA stems from the disorder of immune function, and the production of autoantibodies can precede the appearance of clinical symptoms [1-2]
.

Anti-citrullinated protein antibody (ACPA) is an important serum marker of RA, which is related to the severity of the disease and the rapid progression of the disease [3]
.

The detection of ACPA is conducive to the early diagnosis of RA and the choice of treatment options
.

In clinical practice, how can individualized treatment be achieved for patients with early-stage RA patients who are positive for ACPA? In this issue, Professor Zhao Dongbao from Shanghai Changhai Hospital shared with us the diagnosis and treatment of an ACPA-positive early RA patient.
I hope it can bring some reference to my colleagues
.

Basic information of the patient: female, 45 years old
.

Chief complaint: Joint swelling and pain in both hands for 3 months
.

History of present illness: 3 months of swelling and pain in the joints of both hands, I used compound betamethasone injection once intramuscularly during treatment at the local hospital.
Although the symptoms were relieved to some extent, the curative effect did not last long
.

He has not been treated with disease-improving anti-rheumatic drugs (DMARDs)
.

In order to seek further treatment, she went to our hospital for medical treatment on January 19, 2020
.

Laboratory examination: erythrocyte sedimentation rate (ESR) 13 mm/h, C-reactive protein (CRP) 3.
1 mg/L, rheumatoid factor (RF) 530 IU/mL↑, anti-cyclic citrullinated peptide antibody (anti-CCP antibody) 356.
5 U/mL↑
.

Physical examination: Tenderness of metacarpophalangeal joints and proximal interphalangeal joints of both hands (+), swelling of the second and third metacarpophalangeal joints and interphalangeal joints (+)
.

Diagnosis: rheumatoid arthritis
.

Comorbidities: No special, no history of hepatitis or tuberculosis
.

Treatment plan: Methotrexate (MTX) 10 mg qw + diclofenac sodium 75 mg qd, after full communication with patients and family members, use the biological agent abatacept 125 mg qw
.

From 2021-3-24, diclofenac sodium was discontinued, and MTX and abatacept were continued
.

Follow-up observation: From 2021-1-19 to 2021-7-21, the patient has been using abatacept therapy
.

The patient's joint swelling and pain was relieved, ESR and CRP were controlled within the normal range, and the level of autoantibodies (RF, anti-CCP antibody) was also significantly reduced (Figure 1)
.

After 6 months of treatment with Abatacept, due to stable disease control and economic reasons, the patient was stopped and replaced with a JAK inhibitor, and continued to combine with MTX to control the disease
.

Figure 1: Index changes during treatment.
Experts comment that RA is one of the main causes of labor loss and disability.
Active interventions in the early stages of RA can induce a higher rate of disease remission and reduce structural damage, and avoid subsequent irreversible damage Occurrence [4]
.

At present, the definition of early RA is still unclear[5].
In clinical studies, the disease course is less than 2 years as early RA
.

The RA treatment guidelines updated by the American College of Rheumatology (ACR) in 2012 recommended that the first 6 months after the onset of symptoms be defined as early RA, during which patients receive more clinical treatment benefits [6]
.

The clinical manifestations of early RA have high non-specificity and are difficult to distinguish, and the detection of autoantibodies can help its diagnosis
.

Among them, RF and ACPA (anti-CCP antibody commonly used in clinical testing) are commonly used auxiliary testing indicators with good sensitivity and specificity
.

Compared with RF, ACPA is more specific in the diagnosis of early RA, and ACPA positivity is associated with higher disease activity and faster imaging progress [3]
.

Therefore, ACPA not only has a high diagnostic value, but also an important factor in predicting the prognosis of the disease
.

For ACPA-positive early RA patients, clinical attention should be paid to timely intervention
.

For a long time, there has not been a unified consensus on the best treatment and intervention measures for early RA
.

However, domestic and international guidelines point out that once a patient is clearly diagnosed with RA, DMARDs should be started immediately, and MTX is an anchoring drug for RA treatment [7-9]
.

If the patient has poor prognostic factors (such as high disease activity, polyarticular swelling and pain, RF or ACPA positive, etc.
), combined biologics can also be considered for treatment [10]
.

Among the existing biological agents, abatacept targeting T cells may bring additional benefits to patients with early ACPA-positive RA.
There is clear research evidence that abatacept is better in ACPA-positive RA patients.
The treatment response rate [11-14]; compared with active conventional treatment (hormones combined with traditional synthetic DMRADs), abatacept combined with MTX treatment of early RA patients can achieve a higher remission rate and good imaging efficacy [15-16 ], this is of great significance for improving the prognosis of patients
.

In the case shared this time, the clinical manifestations of the patient were swelling and pain in the joints of both hands, and the course of the disease was short
.

At the time of admission to the hospital, although the inflammation indicators (ESR and CRP) were in the normal range, the autoantibody (RF and ACPA) titers were high, and they belonged to ACPA-positive early RA patients
.

The patient has not been treated with any targeted drugs before, but considering his poor prognostic factors, after adequate communication and exchanges with the patient and his family, he decided to adopt the MTX combined with Abatacept for treatment
.

The patient started using abatacept in January and continued to use it until July.
During this period, his condition was stable, his autoantibody levels continued to decrease, and his joint symptoms improved
.

RA is a highly heterogeneous disease, and the detection of autoantibody status has a high reference value for its early diagnosis and the selection of individualized treatment options
.

The biological agent Abatacept caters to the current trend of individualized treatment of RA, and its remarkable efficacy in ACPA-positive patients has brought us new options
.

 Expert profile Professor Zhao Dongbao, Department of Rheumatology and Immunology, Shanghai Changhai Hospital, Professor, Chief Physician, Ph.
D.
Supervisor, Shanghai Leading Talent, Shanghai Excellent Discipline Leader, and Silver Medal for Yucai in Military Colleges, Member of the Standing Committee of the Chinese Medical Association Rheumatology Branch, Chinese Medical Association Member of the Standing Committee of the Chinese Physician Association, Member of the Osteoporosis Group of the Chinese Association of Rheumatologists The deputy chairman of the committee has won 6 National Natural Science Foundation of China, Shanghai Leading Talents Program, Shanghai New Hundred Talents Program, Shanghai Science and Technology Commission Major, Key Points and Army Funds and more than 20 references [1] Deane KD, Holers VM.
Rheumatoid Arthritis Pathogenesis,Prediction,and Prevention:An Emerging Paradigm Shift[J].
Arthritis Rheumatol,2021,73 (2):181-193.
[2]Wang Dan, Liu Jing, Yuan Guohua.
Autoimmunity in preclinical rheumatoid arthritis [J].
Chinese Journal of Clinical Immunity and Allergy, 2019,13(4):322-327.
[3]van der Helm-van Mil AH,Verpoort KN,Breedveld FC,et al.
Antibodies to citrullinated proteins and differences in clinical progression of rheumatoid arthritis[J].
Arthritis Res Ther,2005,7:R949-R958.
[4].
Preliminary rheumatoid arthritis—opportunities and challenges for the transformation from treatment to prevention[J].
Chinese Journal of Rheumatology, 2018,22(9):577-579.
[5]Demoruelle MK,Deane KD.
Treatment strategies in early rheumatoid arthritis and prevention of rheumatoid arthritis[J].
Curr Rheumatol Rep,2012,14(5):472-80.
[6]Singh JA,Furst DE,Bharat A,et al.
2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis[J] .
Arthritis Care Res(Hoboken),2012,64(5):625-39.
[7]Combe B,Landewe R,Daien CI,et al.
2016 update of the EULAR recommendations for the management of early arthritis[J].
Ann Rheum Dis,2017,76(6):948-959.
[8]Smolen JS,LandewéRBM,Bijlsma JWJ,et al.
EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:2019 update[ J].
Ann Rheum Dis,2020,79(6):685-699.
[9]Smolen JS,LandewéR,Bijlsma J,et al.
EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update[J].
Ann Rheum Dis,2017,76(6):960-977.
[10]Singh J,Saag K,Bridges S,et al.
2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis[J].
Arthritis&Rheum, 2015; 68(1):9 .
[11]Gottenberg JE,Courvoisier DS,Hernandez MV,et al.
Brief Report:Association of Rheumatoid Factor and Anti-Citrullinated Protein Antibody Positivity With Better Effectiveness of Abatacept: Results From the Pan-European Registry Analysis[J].
Arthritis Rheumatol ,2016,68(6):1346-52.
[12]Schiff M,Weinblatt ME,Valente R,et al.
Head-to-head comparison of subcutaneous abatacept versus adalimumab for rheumatoid arthritis:two-year efficacy and safety findings from AMPLE trial[J].
Ann Rheum Dis,2014,73(1):86-94.
[13]Fleischmann R,Weinblatt M,Ahmad H,et al.
Efficacy of Abatacept and Adalimumab in Patients with Early Rheumatoid Arthritis With Multiple Poor Prognostic Factors:Post Hoc Analysis of a Randomized Controlled Clinical Trial(AMPLE)[J].
Rheumatol Ther,2019,6(4):559-571.
[14]Harrold LR,Litman HJ,Connolly SE,et al.
Effect of Anticitrullinated Protein Antibody Status on Response to Abatacept or Antitumor Necrosis Factor-αTherapy in Patients with Rheumatoid Arthritis:A US National Observational Study[J].
J Rheumatol,2018,45(1):32-39.
[15]Hetland ML,Haavardsholm EA,Rudin A,et al.
Active conventional treatment and three different biological treatments in early rheumatoid arthritis: phase IV investigator initiated,randomised,observer blinded clinical trial[J].
BMJ,2020,371:m4328.
[16]Westhovens R,Robles M, Ximenes AC,et al.
Clinical efficacy and safety of abatacept in methotrexate-naive patients with early rheumatoid arthritis and poor prognostic factors[J].
Ann Rheum Dis,2009,68(12):1870-7.
This article is only used to Scientific information provided by medical and health professionals does not represent the position of the platformThis article is only used to provide scientific information to medical and health professionals, and does not represent the platform's position
.