Quest Diagnostics
Understand autoimmune screening results for faster diagnoses and care
Your role as a primary care provider is pivotal. Help improve patient outcomes by using a comprehensive screening approach.
To support faster autoimmune diagnoses with fewer steps, Quest Diagnostics has developed this tool to provide guidance on the clinical significance of results for ANA and over 20 disease-specific biomarkers.
Confidently navigate the autoimmune screening process
? Identify patients at risk: Vague, nonspecific symptoms can make autoimmune disease difficult to identify. Common symptoms include: Digestive problems, Fever, Fatigue, Joint pain, Muscle weakness or pain, Rash, Shortness of breath.
? Screen beyond ANA: For some autoimmune diseases like rheumatoid arthritis (RA) and autoimmune thyroid disease (ATD), antinuclear antibodies (ANA) are only prevalent in a minority of patients with those conditions. Quest's autoimmune screening panels test for ANA plus the most informative disease-specific markers, so you can help empower a faster differential diagnosis, or identify patients with multiple autoimmune conditions.
? Interpret results: This section provides detailed guidance on what positive and negative screening results of ANA and 20+ specific antibodies mean for your patient.
? Provide informed referrals: Help rheumatologists know where to focus. Comprehensive autoimmune screening delivers more answers with a single test code, so you can empower faster and more informed referrals and help limit disease progression.
? Monitor risk: 25% of Americans with an autoimmune condition have more than 1 disease, making it critical for primary care providers to monitor comorbidities. Patients with an autoimmune disease may be at increased risk for other conditions, including but not limited to: Atherosclerosis, Cancer, Depression, Heart disease, Interstitial lung disease, Kidney disease, Osteoporosis, Pregnancy complications.
Antibody prevalence (%) in rheumatic and related diseases and healthy individuals
| Biomarker | SLE<sup>2,3</sup> | MCTD<sup>4</sup> | SSc<sup>5</sup> | SS<sup>6</sup> | PM/DM<sup>7</sup> | APS<sup>8</sup> | ATD | RA<sup>9</sup> | Early RA<sup>b</sup> | All RA | HI |
|---|---|---|---|---|---|---|---|---|---|---|---|
| ANA<sup>10-12</sup> | 90-95 | 90-100 | 85-95<sup>c</sup> | 50-60 | 50-60 | 40-70 | 10-20 | 20 | 38 | 20-30 | 5 |
| B2GP<sup>13-16</sup> | 7-22 | 7 | 5 | 78<sup>d</sup> | 5 | 1 | <3 | <3 | <3 | <1 | <1 |
| C3 and C4 complement<sup>17</sup> | 73<sup>e</sup> | ||||||||||
| Cardiolipin<sup>4,13-16</sup> | 7-21 | 15 | 4 | 81<sup>d</sup> | 1 | 3 | 5-10 | <3 | <3 | <1 | <1 |
| CCP<sup>18-20</sup> | 1 | 3 | 1 | 62 | 71 | 1 | <3 | <3 | <3 | <1 | <1 |
| CENP-B<sup>11</sup> | 2-5 | 2-5 | 20-40<sup>c,f</sup> | 5-10 | 1-3 | <3 | <3 | <3 | <3 | <3 | <3 |
| Chromatin<sup>11</sup> | 40-70 | 5-18 | <3 | <3 | <3 | <3 | <3 | <3 | <3 | <3 | <3 |
| dsDNA<sup>11</sup> | 40-70 | <3 | <3 | <3 | <3 | <3 | <3 | <3 | <3 | <3 | <3 |
| Jo-1<sup>11</sup> | 1-3 | <2<sup>g</sup> | 1-3 | <2 | 15-30 | <1 | <1 | <1 | <1 | <1 | <1 |
| MCV<sup>18,19,21</sup> | 12-36 | 10 | 10 | 27 | 78 | 71 | ≤5 | 5 | 5-25 | <3 | <1 |
| RF<sup>18-20,22</sup> | 15-35 | 50-60 | 20-30 | 75-95 | 20 | 72 | 77 | 5-25 | <3 | <1 | <1 |
| RNP<sup>11</sup> | 10-40 | 100 | 5-15 | <3 | 5-15 | <3 | <3 | <3 | <3 | <3 | <3 |
| Scl-70<sup>11</sup> | 0-5 | <3<sup>h</sup> | 20-40 | <3 | <3 | <1 | <1 | <1 | <1 | <1 | <1 |
| Sm<sup>11</sup> | 5-20 | <2 | <2 | <1 | <1 | <1 | <1 | <1 | <1 | <1 | <1 |
| Sm/RNP<sup>23,24</sup> | 30 | 100 | 4 | 9 | 5 | <3 | <3 | <3 | <3 | <3 | <3 |
| SS-A/Ro<sup>11</sup> | 40-70 | <3 | 3-10 | 60-90 | <3 | <3 | <3 | <3 | <3 | <3 | <3 |
| SS-B/La<sup>11</sup> | 15-30 | <3 | 1-5 | 60-80 | 5-15 | <3 | <3 | <3 | <3 | <3 | <3 |
| TPO<sup>25-27</sup> | 4-13 | 5-21 | 10 | >90 | <3 | <3 | <3 | <3 | <3 | <3 | <3 |
Abbreviations: ANA, antinuclear antibody; APS, antiphospholipid syndrome; ATD, autoimmune thyroid disease (ie, Graves disease or Hashimoto thyroiditis); B2GP, beta-2-glycoprotein; CCP, cyclic citrullinated peptide; CENP-B, centromere B; dsDNA, double-stranded DNA; HI, healthy individuals; Jo-1, histidyl-tRNA synthetase; MCTD, mixed connective tissue disease; MCV, mutated citrullinated vimentin; PM/DM, polymyositis/dermatomyositis; RA, rheumatoid arthritis; RF, rheumatoid factor; RNP, ribonucleoprotein; Scl-70, scleroderma-70 (topoisomerase 1); SLE, systemic lupus erythematosus; Sm, Smith; Sm/RNP, Smith/ribonucleoprotein; SS, Sjögren's syndrome; SS-A, SS-B, Sjögren antibodies A and B; SSc, systemic sclerosis; TPO, thyroid peroxidase.
<sup>a</sup> Highlighted antibodies represent classification or diagnostic criteria for the disease. Note that antibodies included in criteria are not always those with the highest prevalence in that disease.
<sup>b</sup> Early RA defined as disease history of <1 year.
<sup>c</sup> CREST syndrome is a variant of systemic sclerosis defined by the presence of calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. Also known as limited cutaneous scleroderma. ANA is present in 70% of CREST patients, and CENP-B is present in 90% to 95%.<sup>20</sup>
<sup>d</sup> IgG type; 49% for cardiolipin IgM and 40% for B2GP IgM.<sup>16</sup>
<sup>e</sup> The prevalence of simultaneously low C3 and C4 levels was higher in 73% of patients with SLE.<sup>17</sup>
<sup>f</sup> The presence of scleroderma-related antibodies (centromere, Scl-70, or RNA polymerase III antibodies) is not necessary or sufficient for diagnosis, but is useful for classification in the absence of diagnostic clinical findings (ie, "skin thickening of the fingers extending proximal to the metacarpophalangeal joints"<sup>5</sup>).
<sup>g</sup> Especially in patients with features of muscle inflammation.
<sup>h</sup> Especially in patients with features of systemic sclerosis.
Interpret results: what do they mean for your patient?
Autoimmune disease may be complex, but getting answers doesn't have to be. This table provides detailed guidance on what positive and negative screening results of ANA and 20+ specific antibodies mean for your patient.
| Component | Clinical indication | Clinical significance |
|---|---|---|
| Antinuclear antibodies (ANA) | General autoimmune disease | Although strongly associated with systemic lupus erythematosus (SLE), a positive ANA may also be present in a large number of autoimmune disorders. Quest's immunofluorescence test screens at a low titer in order to enhance sensitivity. A high titer (>1:160) strongly suggests autoimmune disease; a low titer (1:40 or 1:80) does not rule it out but may also be found in a minority of healthy individuals.<sup>28</sup> ANA patterns may help guide diagnosis, and Quest uses the International Consensus on ANA Patterns (ICAP) reporting guidelines.<sup>29</sup> Individuals with negative results on the ANA IFA usually also have negative results when tested for specific antinuclear antibodies using immunoassay. Exceptions include Jo-1 antibody in some patients with myositis, and SS-A antibody in some patients with SLE or Sjögren's syndrome.<sup>30</sup> |
| Rheumatoid factor (RF) | Rheumatoid arthritis (RA) | Although strongly associated with RA, RF is found in a large variety of autoimmune and infectious disorders and even in healthy individuals. It is present in many patients with RA, but its poor specificity limits its use as a diagnostic marker of autoimmune disease.<sup>22</sup> |
| Cyclic citrullinated peptide (CCP) antibody (IgG) | RA | The CCP antibody test detects a variety of antibodies against proteins which have undergone a modification in which some amino acids have been changed (into citrulline). These new parts of the proteins are highly immunogenic in patients with RA, and these antibodies are very specific for RA, although they are only found in more than half of patients.<sup>9</sup> Positivity for anti-CCP also increases the risk of more severe disease.<sup>12</sup> |
| Mutated citrullinated vimentin (MCV) antibody | RA | Antibodies to MCV are a specific form of anti-CCP antibody which are directed against 1 specific target. Vimentin is a protein expressed by synovial cells in inflamed joints in RA in a mutated form which enhances citrullination. MCV antibodies are present in many patients with RA and may be positive in approximately 15% of CCP-negative patients, enhancing diagnostic sensitivity.<sup>18</sup> |
| dsDNA antibody | Systemic lupus erythematosus (SLE) | Antibodies to double-stranded DNA are very specific for SLE. Their presence is associated with increased risk of lupus nephritis, and levels are useful for monitoring activity.<sup>2</sup> Quest has 2 assays for anti-dsDNA. The assay included in ANAlyzeR™ uses an organism called Crithidia luciliae which has an organelle with dsDNA. The other method is an immunoassay which may be more useful for monitoring patients.<sup>31</sup> |
| Chromatin | SLE | Chromatin refers to the assembly of DNA into organized structures (nucleosomes) which combine to make up the individual chromosomes. Most patients with anti-dsDNA antibodies also have anti-chromatin antibodies and their presence can help to confirm a diagnosis of SLE.<sup>32</sup> |
| Sm antibody | SLE | The Smith (Sm) antibody test detects antibodies to a protein component of small ribonucleoproteins. It is highly specific for SLE, although it is only detected in some patients.<sup>2</sup> |
| Complement components | SLE | Complement refers to a series of proteins which are part of the inflammatory response. The 2 major components are C3 and C4. Low levels of these proteins may be found in severe acute inflammatory disorders, especially active SLE and cryoglobulinemic vasculitis.<sup>17</sup> |
| Sm/RNP antibody | Lupus and mixed connective tissue disease | The Sm/RNP test detects an antibody against a unique target in small ribonucleoproteins which includes both Sm and RNP. It is present in a minority of patients with anti-Sm and/or anti-RNP, but its clinical significance is unclear.<sup>33</sup> |
| RNP antibody | Lupus and mixed connective tissue disease | RNP antibodies are directed against the RNA portion of small ribonucleoproteins. These antibodies are present in some patients with SLE and are also highly associated with an overlap syndrome called mixed connective tissue disease (MCTD).<sup>34</sup> |
| Jo-1 antibody | Polymyositis and anti-synthetase syndrome | Jo-1 antibody is 1 of several myositis-specific antibodies associated with a particular type of myositis called anti-synthetase syndrome. This syndrome may include both skin and muscle pathology, as well as increased risk of chronic interstitial lung disease.<sup>7</sup> |
| Sjögren's antibodies (SS-A,SS-B) | Sjögren's syndrome | Sjögren's syndrome is the combination of a systemic rheumatic disorder with a complex defined by inflammation of salivary and lacrimal glands. There are 2 associated antibodies: anti-SS-A and anti-SS-B (also known as Ro and La, respectively). Anti-SS-A is present in the majority of patients with Sjögren's syndrome and may also be present in a minority of patients with SLE or RA. Anti-SS-B is present in a smaller percentage of Sjögren's syndrome patients.<sup>6</sup> |
| Scleroderma antibodies | Systemic sclerosis | Two antibodies help to differentiate 2 types of scleroderma (progressive systemic sclerosis). Scl-70 antibody (also called anti-topoisomerase) is very specific for scleroderma, may be found in more than half patients, and is associated with the diffuse type. Anti-centromere antibody may be found in some scleroderma patients and is associated with the limited type with CREST: calcinosis, Raynaud's phenomenon, esophageal immotility, sclerodactyly, and telangiectasia.<sup>5</sup> |
| Centromere B antibody | CREST syndrome | Anti-centromere antibody is 1 of the 2 antibodies that help to differentiate 2 types of scleroderma (progressive systemic sclerosis). It may be found in many scleroderma patients and is associated with the limited type (with CREST: calcinosis, Raynaud's phenomenon, esophageal immotility, sclerodactyly, and telangiectasia.<sup>5</sup>) |
| Antiphospholipid antibodies | Antiphospholipid syndrome | Antiphospholipid syndrome is a disorder characterized by recurrent vascular thrombosis. Two antibodies associated with this syndrome are antibodies to the phospholipid cardiolipin and antibodies to a phospholipid-binding protein called beta-2-glycoprotein I. The testing in the ANAlyzeR panel includes IgG, IgA, and IgM antibodies to both.<sup>13</sup> |
| Cardiolipin antibodies (IgA, IgG, IgM) | Antiphospholipid syndrome | Antiphospholipid syndrome is a disorder characterized by recurrent vascular thrombosis. Two antibodies associated with this syndrome are antibodies to the phospholipid cardiolipin and antibodies to a phospholipid-binding protein called beta-2-glycoprotein I. The testing in the ANAlyzeR panel includes IgG, IgA and IgM antibodies to both.<sup>13</sup> |
| Thyroid peroxidase antibody | Autoimmune thyroid disease | Thyroid peroxidase is an enzyme involved in the production of thyroid hormone. Anti-TPO antibodies are present in greater than 90% of patients with Hashimoto disease and many patients with Graves Disease.<sup>26</sup> |
Provide informed referrals
Help rheumatologists know where to focus. Comprehensive autoimmune screening delivers more answers with a single test code,<sup>1</sup> so you can empower faster and more informed referrals—and help limit disease progression.
- Recommended time after symptom onset to visit rheumatologist is within 6 weeks<sup>35</sup>
- Current reported wait times for new patients to see rheumatologist is over 6 months<sup>36</sup>
Monitor and manage comorbidity risk
25% of Americans with an autoimmune condition have more than 1 disease,<sup>37</sup> making it critical for primary care providers to monitor comorbidities. Patients with an autoimmune disease may be at increased risk for other conditions, including but not limited to:
- Atherosclerosis
- Cancer
- Depression
- Heart disease
- Interstitial lung disease
- Kidney disease
- Osteoporosis
- Pregnancy complications
Key tips to interpreting results
The importance of positive and negative results. If the ANA IFA result is positive, but specific antibody results in a panel, cascade, or individual supplement are negative, an autoimmune disease may still be present. While negative results won't lead to a differential diagnosis, they can be an important part of an informed referral to a rheumatologist.
Knowing the ANA titer can be helpful in interpreting positive ANA results. A high titer (>1:160) strongly suggests autoimmune disease; a low titer (1:40 or 1:80) does not rule it out but may also be found in a minority of healthy individuals. Higher titers are generally associated with greater likelihood of autoimmune disease.<sup>38</sup>
Empower faster autoimmune diagnoses and referrals with just 1 blood draw
Expedite diagnoses and improve outcomes with comprehensive autoimmune testing that is more specific than ANA alone.<sup>1</sup>
ANAlyzeR™
ANA, IFA, with Reflex Titer/Pattern, Systemic Autoimmune Panel 1
Test code 36378
Fixed panel of 20+ analytes that gives a full-picture view (whether ANA is positive or negative), to support differential diagnosis, especially for patients with more than 1 autoimmune condition.
Cascade
ANA, IFA, Cascade and Rheumatoid Arthritis Panel 2, with Reflexes
Test code 94954
Automatic reflex panel that screens for the 8 most common autoimmune diseases, where positive ANA results reflex to a tiered cascade of specific antibodies.
The component tests may also be ordered individually.
ANAlyzeR™: ANA Screen, IFA, with Reflex to Titer/Pattern (249); dsDNA Antibody, Crithidia IFA with Reflex to Titer (37092); Complement Component C3c and C4c (351, 353); Chromatin (nucleosomal) Antibody (34088); Sm Antibody (37923); Sm/RNP Antibody (38567); RNP Antibody (19887); Rheumatoid Factor Antibodies (IgA, IgG, IgM) (19705); Mutated Citrullinated Vimentin (MCV) antibody (13238); Cyclic Citrullinated Peptide (CCP) Antibody (IgG) (11173); Sjogren's Antibodies (SS-A, SS-B) (38568, 38569); Scleroderma Antibody (Scl-70) (4942); Jo-1 Antibody (5810); Centromere Protein B (CENP-B) Antibody (16088); Beta-2-Glycoprotein I Antibodies (IgG, IgA, IgM) (36552, 36553, 36554); Cardiolipin Antibodies (IgA, IgG, IgM) (4661, 4662, 4663); Thyroid Peroxidase Antibodies (TPO) (5081)
Cascade: ANA screen, IFA, with Reflex to Titer/Pattern (249); and Reflex to Multiplex 11 Ab Cascade Rheumatoid Factor (19946); Cyclic Citrullinated Peptide (CCP) Antibody (IgG) (11173); Mutated Citrullinated Vimentin (MCV) Antibody (13238)
Process Comparison
Comprehensive autoimmune screening:
- 1 blood draw, fewer steps to treatment<sup>a</sup>
- PCP visit & comprehensive autoimmune screening
- Follow up & referral with disease-specific insights
- Rheumatologist visit for diagnosis & treatment
Screening with ANA alone:
- Multiple blood draws, more steps to treatment<sup>a</sup>
- PCP visit & ANA screening
- Follow-up visit & referral
- Rheumatologist visit & disease-specific testing
- Follow-up visit for diagnosis & treatment
<sup>a</sup> The number of visits, referrals, and ordered tests may vary based on the specific patient case and the clinician's decisions.
References
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