Rheumatoid Arthritis: Diagnosis, Treatment, and Concerns

Q: Rheumatoid Arthritis: Diagnosis, Treatment, and Concerns

Hello, thank you for your questions. <br>Here are my consolidated responses：<br>1. <br>Can anti-CCP antibodies be present intermittently? (There was a significant difference in test results just five days apart.) Could differences in testing methods cause varying results? Are the

Regarding the diagnosis and medication use for rheumatoid arthritis?

Dear Director Gao,
I apologize for the length of my inquiry and hope you can take the time to clarify my doubts.
Thank you!
About a year and a half ago, blood tests revealed that my rheumatoid factor (RF) was positive at 44, with a standard value of 0-20.
Six months later, my RF was positive at 16.1, with a standard value of <14.
At the same time, I was tested for anti-cyclic citrullinated peptide (anti-CCP) antibodies, which returned negative at <7.00, with a reference value of <17.00.
In March of this year, my third RF test showed a positive result of 16.3, with a standard value of <14.
Two weeks ago, on June 10, my fourth RF test was negative at 15.4, with a standard value of <15.9.
I also tested for anti-CCP again, and this time the result was positive at 6.95, with a reference value of 1.5-1.93.
My erythrocyte sedimentation rate (ESR) was normal at 11, and my high-sensitivity C-reactive protein (hsCRP) was also normal at 0.04.

Worried about my condition, I went to a large testing facility on June 15 to retest for anti-CCP, and the result was normal at 1.91 (reference value <7.0 (-), 7-10 equivocal, >10 (+) EliA U/mL).
The 1.91 result seems significantly lower than the standard value.
Over the past year, I have not experienced any significant joint symptoms; however, in the last three months, I have had intermittent joint pain, with some pain being unilateral and some being symmetrical.
The symmetrical pain is notably in my fingers and wrists, while the unilateral pain is in my right shoulder, right elbow, and right toe.
The pain varies from all-day discomfort to being very painful one day and better the next.
The painful areas seem to be fixed for fingers and toes, while other areas are variable, sometimes painful and sometimes not.
The intensity of pain also fluctuates daily.
I would like to ask you:
1.
Can anti-CCP antibodies fluctuate and be present one moment and absent the next? (There was only a five-day gap between tests, yet the results varied significantly.) Could differences in testing methods account for the discrepancies? Are there variations in the testing targets or processes, given that the standard values set for the two tests were different?
2.
If anti-CCP antibodies are positive, does that mean the disease has already developed, or does it guarantee that rheumatoid arthritis will occur? (I have some joint pain, but my ESR and CRP values are normal.) Should I start medication treatment, or under what circumstances should treatment begin? I am very concerned about the possibility of needing lifelong medication.
3.
Can these antibodies (anti-CCP and RF) appear and then disappear? Or once they appear, are they permanent? I noticed that in the June 10 test, RF was negative at 15.4 (with a standard value of 15.9).
If we consider the previous standard value of <14, then 15.4 would be elevated, but with the new standard value of <15.9, it is now considered negative.
Is this due to a relaxation of the standard values, or is it genuinely negative?
4.
If RF antibodies are present and the pain is intermittent with normal inflammatory markers, is it possible that this is not rheumatoid arthritis but another autoimmune disease? (I have seen reports suggesting that other autoimmune diseases can also cause joint pain.) Should I undergo further testing for other autoimmune diseases?
5.
Does rheumatoid arthritis have periods of flare-ups and remissions? Does the location of pain change? Currently, I experience pain in one area today and a different area tomorrow; sometimes a finger hurts, and then it doesn’t, but suddenly it hurts again with certain movements.
Does this indicate a lack of inflammation? Can joints and bones still be damaged when there is no inflammation? I have read that this disease has active and remission phases; how can one differentiate between them? (If I am pain-free in the morning but in pain in the afternoon, does that count as an active phase or a remission phase?)
Finally, I would like to understand if, unfortunately, I need to take medication, are there options among these medications that do not cause hair loss, baldness, darkening of the skin, or weight gain? (Non-quinine and non-steroidal medications) Is medication use lifelong, or can I stop if my values are normal and I am not in pain? Will side effects from medications (skin color, hair, weight) return to normal after discontinuation? (I have read extensively and found that rheumatoid medications can have these side effects, which has made me quite anxious about the prospect of needing to take these medications for life, facing physical discomfort along with changes in appearance.)
Thank you for your assistance!

Mi Ya, 30~39 year old female. Ask Date: 2021/06/23

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your questions.
Here are my consolidated responses:
1.
Can anti-CCP antibodies be present intermittently? (There was a significant difference in test results just five days apart.) Could differences in testing methods cause varying results? Are there differences in the testing targets or processes, as I noticed that the reference values set for both tests were different? --> Different laboratories may have varying reference ranges.
Test results can fluctuate, especially when they are close to the normal range, which can lead to situations where results are sometimes normal and sometimes abnormal.
It is advisable not to test too frequently to avoid unnecessary confusion.
2.
If anti-CCP antibodies are positive, does that mean the disease has developed, or will rheumatoid arthritis definitely occur? (I have some joint pain, but my ESR and CRP values are normal.) Should I start medication treatment, or under what circumstances should treatment begin? I am concerned about having to take medication for life.
--> Anti-CCP is just one diagnostic criterion for rheumatoid arthritis; a positive result does not necessarily mean one is ill.
We do not rely solely on blood test results for diagnosis; clinical symptoms must also be considered.
3.
Can these antibodies (anti-CCP and RF factor) disappear after appearing, or once they appear, do they remain? I found that in the June 10 test, RF was negative with a value of 15.4 (the reference value is 15.9).
If we consider the previous reference value of <14, then 15.4 is above the limit, but this time the reference value shows <15.9, making it negative.
Is this due to a relaxation of the reference value or is it truly negative? --> As in question 2, please do not fixate on test values.
Even if CCP and RF are detected, it does not mean the body is diseased.
The body may show abnormal values without developing a disease.
It is impossible for all test values to be completely within the normal range; there will be fluctuations.
Your test values are very close to the normal range, making them of low reference value.
We place greater emphasis on clinical symptoms.
4.
If RF antibodies are present, and the pain is intermittent with normal inflammatory markers, could it be something other than rheumatoid arthritis, such as another autoimmune disease? (I have seen reports suggesting that other autoimmune diseases can also cause joint pain.) Should I undergo further testing for other autoimmune diseases? --> It is possible that it is not rheumatoid arthritis.
If the recurring pain is truly bothersome, I recommend consulting a nearby allergist, immunologist, or rheumatologist for a proper examination of the joints and to arrange further testing, so you do not take unnecessary paths.
Many online sources are difficult to verify, so please do not take them at face value.
5.
Does rheumatoid arthritis fluctuate between good and bad periods? Does the location of the pain change? Currently, I sometimes feel pain in one area, and the next day it shifts to another; sometimes a finger hurts, sometimes it does not, but suddenly it hurts again with certain movements, or it may hurt less after a day or two.
Does this indicate no inflammation? Can joints and bones still be damaged when there is no inflammation? I read that this disease has active and remission phases.
How can one distinguish between them? (If it does not hurt in the morning but hurts in the afternoon, does that count as an active or remission phase?) --> In the early stages of rheumatoid arthritis, pain can indeed move around, so it is essential to have a professional physician make the assessment.
Your description of symptoms cannot replace a professional evaluation of your joints.
6.
Lastly, if it unfortunately comes to needing medication, are there options among these medications that do not cause hair loss, baldness, darkening of the skin, or weight gain? (Non-quinine and non-steroidal medications) Is medication use lifelong, or can it be stopped if values are normal and there is no pain? Can side effects from medications (skin color, hair, weight) return to normal after stopping the medication? --> If medication is necessary, you can express your concerns to your physician, who will adjust the type of medication based on your worries.
If it is rheumatoid arthritis, long-term medication is indeed required; however, after symptoms improve, the physician will gradually reduce the dosage.
Whether medication can be completely stopped depends on the severity of the disease.
Most side effects of medications will lessen or disappear after stopping or reducing the medication.
Lastly, I remind you that in situations where it is difficult to discern the truth of online posts, excessive reading can increase anxiety.
It is better to have a physician personally assess your joints.
Therefore, if you are truly concerned and your symptoms are bothersome, I recommend seeking help from a nearby allergist, immunologist, or rheumatologist.
The Allergy, Immunology, and Rheumatology Department at Changhua Hospital cares about you.

Reply Date: 2021/06/23

More Info

Understanding rheumatoid arthritis (RA) and its complexities can be quite overwhelming, especially when faced with fluctuating symptoms and various test results. Your concerns are valid, and it’s important to address them comprehensively.

1. Anti-CCP Antibodies and Their Variability: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are specific markers for rheumatoid arthritis. However, their levels can fluctuate due to various factors, including the timing of the test, the laboratory methods used, and even the individual’s immune response. It’s not uncommon for test results to vary slightly, especially if different laboratories or testing methods are employed. If you see a significant difference in results within a short time frame, it may be worth discussing with your healthcare provider to ensure consistency in testing methods.

2. Implications of Positive Anti-CCP: A positive anti-CCP test is a strong indicator of rheumatoid arthritis, but it does not guarantee that you will develop the disease. Many individuals can have positive markers without ever developing RA. The presence of symptoms, such as joint pain, alongside normal inflammatory markers (like ESR and CRP) suggests that while you may have some underlying issues, it may not necessarily be RA. Treatment decisions should be based on a comprehensive evaluation of your symptoms, lab results, and overall health status. If your symptoms are mild and manageable, immediate medication may not be necessary, but close monitoring is essential.

3. Antibody Dynamics: It is possible for RF (rheumatoid factor) and anti-CCP antibodies to fluctuate over time. Some individuals may experience periods where these antibodies are undetectable, particularly if they are not experiencing active disease. The interpretation of RF levels can also depend on the reference range used by the laboratory. In your case, a RF level of 15.4 could be considered negative based on the adjusted reference range, which indicates that the interpretation of these tests can be nuanced.

4. Differential Diagnosis: Joint pain can arise from various conditions, not just RA. Other autoimmune diseases, such as lupus or psoriatic arthritis, can also cause similar symptoms. If your RF and anti-CCP levels are not consistently high and inflammatory markers remain normal, it may be prudent to explore other potential causes of your joint pain. Additional tests may be warranted to rule out other autoimmune conditions.

5. Fluctuating Symptoms: RA is characterized by periods of flare-ups and remission. It is common for symptoms to vary in intensity and location. Pain that shifts from one joint to another or fluctuates in severity does not necessarily indicate active inflammation. During periods of remission, joint damage can still occur, particularly if there is underlying inflammation that is not being adequately managed. Understanding your body’s patterns can help you communicate effectively with your healthcare provider about your treatment needs.

6. Medication Concerns: If medication becomes necessary, there are options available that may have fewer side effects, including some that do not typically cause hair loss or weight gain. It’s crucial to have an open dialogue with your rheumatologist about your concerns regarding medication side effects. Many patients find that with proper management, they can maintain a good quality of life without significant adverse effects. The duration of medication use can vary; some patients may need to stay on medication long-term, while others may be able to taper off if their disease is well-controlled.

7. Managing Anxiety and Expectations: It’s understandable to feel anxious about potential long-term medication use and its effects on your appearance and health. Engaging in supportive therapies, such as counseling or support groups, can help manage these feelings. Remember that many patients with RA lead fulfilling lives with effective management strategies.

In conclusion, your situation requires careful monitoring and open communication with your healthcare provider. Regular follow-ups and possibly a referral to a rheumatologist specializing in autoimmune diseases may provide you with the best care. It’s essential to address both your physical symptoms and emotional well-being as you navigate this journey.

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