Scope - British Columbia



DRAFT: C-Reactive Protein and Erythrocyte Sedimentation Rate TestingDRAFT FOR EXTERNAL REVIEW: The online questionnaire is available at guideline applies to the clinical use of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as investigative tests in adults aged 19 years and over.Key RecommendationsIn BC the ESR will only be performed if a written indication is provided on the requisition. If both CRP and ESR are ordered, only CRP is payable. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iT1aa8gN","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":80,"uris":[""],"uri":[""],"itemData":{"id":80,"type":"webpage","title":"Laboratory Services Outpatient Payment Schedule - Province of British Columbia","abstract":"laboratory services outpatient payment schedule","URL":"","language":"eng","author":[{"family":"Health","given":"Ministry","dropping-particle":"of"}],"accessed":{"date-parts":[["2018",6,13]]}}}],"schema":""} 1The only indication for CRP assessment in asymptomatic individuals is in the stratification of cardiovascular risk.CRP may be used to evaluate patients with unexplained symptoms or a deterioration of health status when: an inflammatory or infectious disease is suspected; anda specific diagnosis is not made effectively by other meansCRP may be used to monitor the activity of temporal (giant cell) arteritis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MSki6wQQ","properties":{"formattedCitation":"\\super 2\\uc0\\u8211{}4\\nosupersub{}","plainCitation":"2–4","noteIndex":0},"citationItems":[{"id":104,"uris":[""],"uri":[""],"itemData":{"id":104,"type":"article-journal","title":"Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria","container-title":"American Journal of Ophthalmology","page":"285-296","volume":"123","issue":"3","source":"ScienceDirect","abstract":"Purpose\nTo ascertain the validity, reliability, sensitivity, and specificity of various signs and symptoms of and diagnostic tests for early diagnosis of giant cell arteritis.\nMethods\nFrom 1973 to 1994, we studied 363 patients who had temporal artery biopsy for suspected giant cell arteritis. All patients underwent detailed clinical evaluation and had erythrocyte sedimentation rates determined; since 1985, 223 patients had their C-reactive protein values estimated. Erythrocyte sedimentation rate and C-reactive protein levels were also estimated in 749 and 138 control subjects, respectively. Signs and symptoms of giant cell arteritis, erythrocyte sedimentation rate, and C-reactive protein levels among patients with positive and negative biopsies were compared.\nResults\nOf the 363 patients, temporal artery biopsy was positive in 106 and negative in 257. The odds of a positive biopsy were 9.0 times greater with jaw claudication (P < .0001), 3.4 times greater with neck pain (P = .0085), 2.0 times greater with an erythrocyte sedimentation rate of 47 to 107 mm/hour (P = .0454), 3.2 times greater with C-reactive protein above 2.45 mg/dl (P = .0208), and 2.0 times greater for age 75 years or more (P = .0105).\nConclusions\nClinical criteria most strongly suggestive of giant cell arteritis include jaw claudication, C-reactive protein above 2.45 mg/dl, neck pain, and an erythrocyte sedimentation rate of 47 mm/hour or more, in that order. C-reactive protein was more sensitive (100%) than erythrocyte sedimentation rate (92%) for detection of giant cell arteritis; erythrocyte sedimentation rate combined with C-reactive protein gave the best specificity (97%).","DOI":"10.1016/S0002-9394(14)70123-0","ISSN":"0002-9394","shortTitle":"Giant Cell Arteritis","journalAbbreviation":"American Journal of Ophthalmology","author":[{"family":"Hayreh","given":"SOHAN SINGH"},{"family":"Podhajsky","given":"PATRICIA A."},{"family":"Raman","given":"REMA"},{"family":"Zimmerman","given":"BRIDGET"}],"issued":{"date-parts":[["1997",3,1]]}}},{"id":103,"uris":[""],"uri":[""],"itemData":{"id":103,"type":"article-journal","title":"Giant Cell Arteritis: Laboratory Predictors of a Positive Temporal Artery Biopsy","container-title":"Ophthalmology","page":"1201-1204","volume":"118","issue":"6","source":"ScienceDirect","abstract":"Purpose\nTo identify laboratory predictors of a positive temporal artery biopsy.\nDesign\nCross-sectional study using retrospective electronic data base review.\nParticipants\nThere were 3001 patients who had a temporal artery biopsy.\nMethods\nThe electronic database of a large health maintenance organization was searched for all patients who had a temporal artery biopsy performed from 1997 to 2006.\nMain Outcome Measures\nOdds ratios for erythrocyte sedimentation rate, C-reactive protein (CRP), and platelet count values associated with a positive temporal artery biopsy.\nResults\nFour hundred fifty-nine cases of biopsy-proven giant cell arteritis were identified. The odds of a positive biopsy were 1.5 times greater with an erythrocyte sedimentation rate of 47 to 107 mm/hr, 5.3 times greater with a CRP >2.45 mg/dL, and 4.2 times greater with platelets >400 000/μL.\nConclusions\nIn this largest population-based giant cell arteritis study in the United States to date, we reaffirm Hayreh's finding of the significance of a CRP level >2.45 mg/dL in predicting a positive biopsy. Our findings support the literature suggesting that CRP and thrombocytosis may be stronger predictors of positive biopsy than erythrocyte sedimentation rate.\nFinancial Disclosure(s)\nThe authors have no proprietary or commercial interest in any of the materials discussed in this article.","DOI":"10.1016/j.ophtha.2010.10.002","ISSN":"0161-6420","shortTitle":"Giant Cell Arteritis","journalAbbreviation":"Ophthalmology","author":[{"family":"Walvick","given":"Matthew D."},{"family":"Walvick","given":"Michael P."}],"issued":{"date-parts":[["2011",6,1]]}}},{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"article-journal","title":"Utility of Erythrocyte Sedimentation Rate and C-Reactive Protein for the Diagnosis of Giant Cell Arteritis","container-title":"Seminars in Arthritis and Rheumatism","page":"866-871","volume":"41","issue":"6","source":"PubMed Central","abstract":"Objectives\n1) To evaluate the utility of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for the diagnosis of giant cell arteritis (GCA) 2) to determine the frequency of normal ESR and CRP at diagnosis of GCA.\n\nMethods\nAll patients undergoing temporal artery biopsy (TAB) between 2000 and 2008 were identified. Only subjects with both ESR and CRP at the time of TAB were included. The medical records of all patients were reviewed.\n\nResults\nWe included 764 patients (65% women), mean age 72.7 (±9.27) years, who underwent TAB. Biopsy was consistent with GCA in 177 patients (23%). Elevated CRP and elevated ESR provided a sensitivity of 86.9% and 84.1% respectively, for a positive TAB. The odds ratio (OR) of a concordantly elevated ESR and CRP for positive TAB was 3.06 (95% CI 2.03, 4.62) while the OR for concordantly normal ESR and CRP was 0.49 (95% CI 0.29, 0.83)., Seven patients (4%) with a positive TAB for GCA had a normal ESR and CRP at diagnosis. Compared to GCA patients with elevated markers of inflammation, a greater proportion of these patients had polymyalgia rheumatica symptoms (p=0.008) while constitutional symptoms, anemia and thrombocytosis were observed less often (p<0.05).\n\nConclusions\nCRP is a more sensitive marker than ESR for a positive TAB that is diagnostic of GCA. There may be clinical utility in obtaining both tests in the evaluation of patients with suspected GCA. A small proportion of patients with GCA may have normal inflammatory markers at diagnosis.","DOI":"10.1016/j.semarthrit.2011.10.005","ISSN":"0049-0172","note":"PMID: 22119103\nPMCID: PMC3307891","journalAbbreviation":"Semin Arthritis Rheum","author":[{"family":"Kermani","given":"Tanaz A."},{"family":"Schmidt","given":"Jean"},{"family":"Crowson","given":"Cynthia S."},{"family":"Ytterberg","given":"Steven R."},{"family":"Hunder","given":"Gene G."},{"family":"Matteson","given":"Eric L."},{"family":"Warrington","given":"Kenneth J."}],"issued":{"date-parts":[["2012",6]]}}}],"schema":""} 2–4, polymyalgia rheumatica ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vJg4vtGl","properties":{"formattedCitation":"\\super 5,6\\nosupersub{}","plainCitation":"5,6","noteIndex":0},"citationItems":[{"id":95,"uris":[""],"uri":[""],"itemData":{"id":95,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica: a prospective follow-up study","container-title":"Seminars in Arthritis and Rheumatism","page":"17-24","volume":"30","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To determine the frequency and clinical features of patients with polymyalgia rheumatica (PMR) and normal erythrocyte sedimentation rate (ESR) at diagnosis or during relapse/recurrence. To evaluate the usefulness of C-reactive protein (CRP) and ESR in the assessment of PMR activity.\nMETHODS: A prospective follow-up study on 177 consecutive patients meeting the criteria for PMR diagnosed over a 5-year period was conducted in two Italian secondary referral centers of rheumatology. At diagnosis and during follow-up, ESR (Westergren method) and CRP (nephelometry) were measured in all patients. Phenotypic analysis of lymphocyte subpopulations was performed on 78 PMR patients at diagnosis. A two-color technique using the association of specific monoclonal antibodies was applied. A control group consisting of 18 healthy adults older than 60 years was matched for age and sex with the PMR patients.\nRESULTS: Ten of 177 (6%) patients had normal ESR values at diagnosis (< or = 30 mm/h). Patients with normal ESR were predominantly men and had lower CRP levels; systemic signs and symptoms were more frequent in patients with higher ESR. The percentages of circulating CD8+ cells were similar in the two groups. CRP values at diagnosis were normal in only 2 of 177 (1%) patients. CRP values were elevated in 9 of 10 patients with normal ESR at diagnosis. Twenty-five episodes of relapse/recurrence with normal ESR occurred in 17 patients. CRP was high in 62% of these episodes. Results of univariate analysis indicated that the 10th percentile for ESR (40 mm/h) and the 70th percentile for CRP (7.8 mg/dL) values at diagnosis were the best cutoff points that discriminate between patients with and without relapse/recurrence. Cox proportional hazards modeling showed that ESR greater than 40 mm/h and CRP greater than 7.8 mg/dL at diagnosis were the two variables that independently increased the risk of relapse/recurrence. However, the relative risk related to ESR was twice than that related to CRP (4.9 vs 2.1).\nCONCLUSION: PMR with a normal ESR at diagnosis was infrequent in our study compared with previous studies. ESR was a superior predictor of relapse than CRP. However, CRP was a more sensitive indicator of current disease activity.","DOI":"10.1053/sarh.2000.8366","ISSN":"0049-0172","note":"PMID: 10966209","shortTitle":"Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica","journalAbbreviation":"Semin. Arthritis Rheum.","language":"eng","author":[{"family":"Cantini","given":"F."},{"family":"Salvarani","given":"C."},{"family":"Olivieri","given":"I."},{"family":"Macchioni","given":"L."},{"family":"Ranzi","given":"A."},{"family":"Niccoli","given":"L."},{"family":"Padula","given":"A."},{"family":"Boiardi","given":"L."}],"issued":{"date-parts":[["2000",8]]}}},{"id":94,"uris":[""],"uri":[""],"itemData":{"id":94,"type":"article-journal","title":"Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study","container-title":"Arthritis and Rheumatism","page":"33-38","volume":"53","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To determine laboratory parameters that may be useful in identifying polymyalgia rheumatica (PMR) patients who require long-term corticosteroid therapy.\nMETHODS: A prospective followup study of 94 consecutive untreated patients with PMR were assessed for relapse/recurrence for a mean of 39 months. This cohort represented all the patients diagnosed over a 4-year period in 2 Italian secondary referral centers. Patients were monitored for clinical signs and symptoms, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum interleukin-6 (IL-6). IL-6 levels were also measured in 43 controls matched to the patients for age and sex.\nRESULTS: The ESR was elevated in 91.5% of the patients prior to therapy initiation, as were CRP in 98.9% and serum IL-6 in 92.6%. Forty-seven (50.0%) patients had at least 1 relapse/recurrence during the followup period and 24 (25.5%) had at least 2. After 4 weeks of prednisone therapy, ESR was elevated in 13.2% patients, CRP in 41.9%, and serum IL-6 in 37.2%. IL-6 levels remained persistently elevated in 9.9% and CRP in 8.7% of patients during the first year of followup, whereas no patient had persistently elevated ESR. Persistently elevated CRP and IL-6 levels were significantly associated with an increased risk of relapse/recurrence. In particular, patients with persistently elevated levels of IL-6 during the first year of therapy had the highest relative risk.\nCONCLUSION: Despite the control of clinical symptoms, corticosteroids do not adequately control the inflammatory process in a subset of patients with PMR who have persistently elevated levels of CRP and IL-6 and who have a higher risk of relapsing.","DOI":"10.1002/art.20901","ISSN":"0004-3591","note":"PMID: 15696567","shortTitle":"Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica","journalAbbreviation":"Arthritis Rheum.","language":"eng","author":[{"family":"Salvarani","given":"Carlo"},{"family":"Cantini","given":"Fabrizio"},{"family":"Niccoli","given":"Laura"},{"family":"Macchioni","given":"Pierluigi"},{"family":"Consonni","given":"Dario"},{"family":"Bajocchi","given":"Gianluigi"},{"family":"Vinceti","given":"Marco"},{"family":"Catanoso","given":"Maria Grazia"},{"family":"Pulsatelli","given":"Lia"},{"family":"Meliconi","given":"Riccardo"},{"family":"Boiardi","given":"Luigi"}],"issued":{"date-parts":[["2005",2,15]]}}}],"schema":""} 5,6, inflammatory arthritis (e.g. rheumatoid arthritis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Ngznvriy","properties":{"unsorted":true,"formattedCitation":"\\super 7,8\\nosupersub{}","plainCitation":"7,8","noteIndex":0},"citationItems":[{"id":89,"uris":[""],"uri":[""],"itemData":{"id":89,"type":"article-journal","title":"Which measure of inflammation to use? A comparison of erythrocyte sedimentation rate and C-reactive protein measurements from randomized clinical trials of golimumab in rheumatoid arthritis","container-title":"The Journal of Rheumatology","page":"1606-1610","volume":"36","issue":"8","source":"PubMed","abstract":"OBJECTIVE: To assess clinical utility of measurements of C-reactive protein (CRP) versus Westergren erythrocyte sedimentation rate (ESR) in evaluating patients with rheumatoid arthritis (RA).\nMETHODS: Data from 3 randomized clinical trials of golimumab involving 1247 patients with RA in which ESR and CRP were obtained at baseline and Week 24, along with standard measures of clinical disease activity [swollen and tender joint counts, global disease activity assessment, composite Disease Activity Scores (DAS) and Clinical Disease Activity Index (CDAI)], were utilized. Result. Both ESR and CRP were significant predictors of swollen joint count (p < 0.001 for each). Only 4.5% of patients with no swollen joints had elevated CRP and normal ESR, but 15.2% had elevated ESR and normal CRP. ESR and CRP correlated significantly (Pearson r = 0.59, p < 0.001) with each other. DAS-ESR and DAS-CRP were highly correlated (r = 0.96, p < 0.001) with each other, although DAS-ESR values were slightly lower than the DAS-CRP values at the upper end of the range (DAS > 8). Both ESR and CRP were significantly associated with CDAI (p < 0.001 for each).\nCONCLUSION: It is not necessary to obtain both ESR and CRP measures for clinical disease activity assessment in clinical trials of RA. Neither test adds significantly to clinical measures of disease activity including joint counts and global assessments. Where available, the CRP alone may be preferred for disease activity assessment as a simple, validated, reproducible, non age-dependent test.","DOI":"10.3899/jrheum.081188","ISSN":"0315-162X","note":"PMID: 19531760","shortTitle":"Which measure of inflammation to use?","journalAbbreviation":"J. Rheumatol.","language":"eng","author":[{"family":"Crowson","given":"Cynthia S."},{"family":"Rahman","given":"Mahboob U."},{"family":"Matteson","given":"Eric L."}],"issued":{"date-parts":[["2009",8]]}}},{"id":76,"uris":[""],"uri":[""],"itemData":{"id":76,"type":"webpage","title":"NRAS - National Rheumatoid Arthritis Society","URL":"","accessed":{"date-parts":[["2018",7,31]]}}}],"schema":""} 7,8 and systemic lupus erythematosus (SLE) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"M0cIWJS6","properties":{"unsorted":true,"formattedCitation":"\\super 9,10\\nosupersub{}","plainCitation":"9,10","noteIndex":0},"citationItems":[{"id":72,"uris":[""],"uri":[""],"itemData":{"id":72,"type":"article-journal","title":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity","container-title":"Clinical Rheumatology","page":"1835-1844","volume":"37","issue":"7","source":"PubMed","abstract":"To examine disease activity parameters in patients with systemic lupus erythematosus (SLE) experiencing flare, infection, both, or neither condition, focusing on erythrocyte sedimentation rate (ESR). This study is a retrospective analysis of 371 consecutive inpatient SLE cases from 2006 to 2015. Cases were classified as flare (n?=?147), infection (n?=?48), both (n?=?23), or neither (n?=?135). ESR levels were correlated to C-reactive protein (CRP), ferritin, anti-dsDNA antibodies, complement C3 reduction, serositis, and erythrocyturia with proteinuria (Pearson's correlation). ESR levels were related to an age- and gender-adapted cut-off value (ESRp). We analyzed mean values of age, ESR, ESRp, CRP, ferritin and distribution of anti-dsDNA antibodies, C3 reduction, serositis, and erythrocyturia with proteinuria. Sensitivity and specificity were calculated via receiver operating characteristic or two-by-two table. Association of parameters with disease activity and infection was tested via two-sided chi square test. ESR correlated moderately with CRP in cases with flare and/or infection (r?=?0.505-0.586). While ESR and CRP were normal in remission, mean values overlapped in cases with flare, infection, or both. ESRp was higher in flare than in infection (p?=?0.048). ESR lost association to activity in infected cases, CRP to infection in flaring cases. ESRp, serositis, and anti-dsDNA antibodies were related to disease activity regardless of infections. Anti-dsDNA antibodies were most sensitive for detecting flares (74%), while serositis, proteinuria with erythrocyturia, anti-dsDNA antibodies, C3 reduction, and ESRp values ≥?2 were most specific. ESR levels were raised by flares, infections, and age; adapting them to age and gender increased their diagnostic value. Obtaining several parameters remains necessary to differentiate flare from infection.","DOI":"10.1007/s10067-018-4093-3","ISSN":"1434-9949","note":"PMID: 29656375","shortTitle":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus?","journalAbbreviation":"Clin. Rheumatol.","language":"eng","author":[{"family":"Sch?fer","given":"Valentin Sebastian"},{"family":"Wei?","given":"Katharina"},{"family":"Krause","given":"Andreas"},{"family":"Schmidt","given":"Wolfgang Andreas"}],"issued":{"date-parts":[["2018",7]]}}},{"id":77,"uris":[""],"uri":[""],"itemData":{"id":77,"type":"article-journal","title":"The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults","container-title":"Rheumatology","page":"e1-e45","volume":"57","issue":"1","source":"academic.","DOI":"10.1093/rheumatology/kex286","ISSN":"1462-0324","journalAbbreviation":"Rheumatology (Oxford)","language":"en","author":[{"family":"Gordon","given":"Caroline"},{"family":"Amissah-Arthur","given":"Maame-Boatemaa"},{"family":"Gayed","given":"Mary"},{"family":"Brown","given":"Sue"},{"family":"Bruce","given":"Ian N."},{"family":"D’Cruz","given":"David"},{"family":"Empson","given":"Benjamin"},{"family":"Griffiths","given":"Bridget"},{"family":"Jayne","given":"David"},{"family":"Khamashta","given":"Munther"},{"family":"Lightstone","given":"Liz"},{"family":"Norton","given":"Peter"},{"family":"Norton","given":"Yvonne"},{"family":"Schreiber","given":"Karen"},{"family":"Isenberg","given":"David"}],"issued":{"date-parts":[["2018",1,1]]}}}],"schema":""} 9,10) and inflammatory bowel disease. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Oj5ihTZ2","properties":{"formattedCitation":"\\super 11\\nosupersub{}","plainCitation":"11","noteIndex":0},"citationItems":[{"id":78,"uris":[""],"uri":[""],"itemData":{"id":78,"type":"article-journal","title":"C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis","container-title":"The American Journal of Gastroenterology","page":"802-819; quiz 820","volume":"110","issue":"6","source":"PubMed","abstract":"OBJECTIVES: Persistent disease activity is associated with a poor prognosis in inflammatory bowel disease (IBD). Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a treatment concept. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity is a priority. The objective was to evaluate the diagnostic accuracy of C-reactive protein (CRP), fecal calprotectin (FC), and stool lactoferrin (SL) for assessment of endoscopically defined disease activity in IBD.\nMETHODS: Databases were searched from inception to November 6, 2014 for relevant cohort and case-control studies that evaluated the diagnostic accuracy of CRP, FC, or SL and used endoscopy as a gold standard in patients with symptoms consistent with active IBD. Sensitivities and specificities were pooled to generate operating property estimates for each test using a bivariate diagnostic meta-analysis.\nRESULTS: Nineteen studies (n=2499 patients) were eligible. The pooled sensitivity and specificity estimates for CRP, FC, and SL were 0.49 (95% confidence interval (CI) 0.34-0.64) and 0.92 (95% CI 0.72-0.96), 0.88 (95% CI 0.84-0.90) and 0.73 (95% CI 0.66-0.79), and 0.82 (95% CI 0.73-0.88) and 0.79 (95% CI 0.62-0.89), respectively. FC was more sensitive than CRP in both diseases and was more sensitive in ulcerative colitis than Crohn's disease.\nCONCLUSIONS: Although CRP, FC, and SL are useful biomarkers, their value in managing individual patients must be considered in specific clinical contexts.","DOI":"10.1038/ajg.2015.120","ISSN":"1572-0241","note":"PMID: 25964225","shortTitle":"C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients","journalAbbreviation":"Am. J. Gastroenterol.","language":"eng","author":[{"family":"Mosli","given":"Mahmoud H."},{"family":"Zou","given":"Guangyong"},{"family":"Garg","given":"Sushil K."},{"family":"Feagan","given":"Sean G."},{"family":"MacDonald","given":"John K."},{"family":"Chande","given":"Nilesh"},{"family":"Sandborn","given":"William J."},{"family":"Feagan","given":"Brian G."}],"issued":{"date-parts":[["2015",6]]}}}],"schema":""} 11High sensitivity (hs) CRP may be used in patients at intermediate cardiovascular risk to help decide whether a statin should be started.In the appropriate clinical context, if CRP is normal, ESR may provide useful information when:Used in combination with other biomarkers in monitoring SLE or other rheumatic conditions where patients do not mount a CRP response. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IeAwpS36","properties":{"unsorted":true,"formattedCitation":"\\super 9,10,12\\nosupersub{}","plainCitation":"9,10,12","noteIndex":0},"citationItems":[{"id":72,"uris":[""],"uri":[""],"itemData":{"id":72,"type":"article-journal","title":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity","container-title":"Clinical Rheumatology","page":"1835-1844","volume":"37","issue":"7","source":"PubMed","abstract":"To examine disease activity parameters in patients with systemic lupus erythematosus (SLE) experiencing flare, infection, both, or neither condition, focusing on erythrocyte sedimentation rate (ESR). This study is a retrospective analysis of 371 consecutive inpatient SLE cases from 2006 to 2015. Cases were classified as flare (n?=?147), infection (n?=?48), both (n?=?23), or neither (n?=?135). ESR levels were correlated to C-reactive protein (CRP), ferritin, anti-dsDNA antibodies, complement C3 reduction, serositis, and erythrocyturia with proteinuria (Pearson's correlation). ESR levels were related to an age- and gender-adapted cut-off value (ESRp). We analyzed mean values of age, ESR, ESRp, CRP, ferritin and distribution of anti-dsDNA antibodies, C3 reduction, serositis, and erythrocyturia with proteinuria. Sensitivity and specificity were calculated via receiver operating characteristic or two-by-two table. Association of parameters with disease activity and infection was tested via two-sided chi square test. ESR correlated moderately with CRP in cases with flare and/or infection (r?=?0.505-0.586). While ESR and CRP were normal in remission, mean values overlapped in cases with flare, infection, or both. ESRp was higher in flare than in infection (p?=?0.048). ESR lost association to activity in infected cases, CRP to infection in flaring cases. ESRp, serositis, and anti-dsDNA antibodies were related to disease activity regardless of infections. Anti-dsDNA antibodies were most sensitive for detecting flares (74%), while serositis, proteinuria with erythrocyturia, anti-dsDNA antibodies, C3 reduction, and ESRp values ≥?2 were most specific. ESR levels were raised by flares, infections, and age; adapting them to age and gender increased their diagnostic value. Obtaining several parameters remains necessary to differentiate flare from infection.","DOI":"10.1007/s10067-018-4093-3","ISSN":"1434-9949","note":"PMID: 29656375","shortTitle":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus?","journalAbbreviation":"Clin. Rheumatol.","language":"eng","author":[{"family":"Sch?fer","given":"Valentin Sebastian"},{"family":"Wei?","given":"Katharina"},{"family":"Krause","given":"Andreas"},{"family":"Schmidt","given":"Wolfgang Andreas"}],"issued":{"date-parts":[["2018",7]]}}},{"id":77,"uris":[""],"uri":[""],"itemData":{"id":77,"type":"article-journal","title":"The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults","container-title":"Rheumatology","page":"e1-e45","volume":"57","issue":"1","source":"academic.","DOI":"10.1093/rheumatology/kex286","ISSN":"1462-0324","journalAbbreviation":"Rheumatology (Oxford)","language":"en","author":[{"family":"Gordon","given":"Caroline"},{"family":"Amissah-Arthur","given":"Maame-Boatemaa"},{"family":"Gayed","given":"Mary"},{"family":"Brown","given":"Sue"},{"family":"Bruce","given":"Ian N."},{"family":"D’Cruz","given":"David"},{"family":"Empson","given":"Benjamin"},{"family":"Griffiths","given":"Bridget"},{"family":"Jayne","given":"David"},{"family":"Khamashta","given":"Munther"},{"family":"Lightstone","given":"Liz"},{"family":"Norton","given":"Peter"},{"family":"Norton","given":"Yvonne"},{"family":"Schreiber","given":"Karen"},{"family":"Isenberg","given":"David"}],"issued":{"date-parts":[["2018",1,1]]}}},{"id":96,"uris":[""],"uri":[""],"itemData":{"id":96,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein","container-title":"Australian Prescriber","page":"93-4","volume":"38","issue":"3","source":".au","abstract":"C-reactive protein is a better indicator of inflammation than the erythrocyte sedimentation rate. It is more sensitive and responds more quickly to changes in the clinical situation. False negative and false positive results are more common when measuring the erythrocyte sedimentation rate. Renal disease, female sex and older age increase the erythrocyte sedimentation rate.","DOI":"10.18773/austprescr.2015.034","language":"en","author":[{"family":"Harrison","given":"Michael"}],"issued":{"date-parts":[["2015",5,31]]}}}],"schema":""} 9,10,12Used in combination with other clinical tests when considering the possibility of low-grade bone and joint infections (e.g. osteomyelitis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UvC14Z7R","properties":{"formattedCitation":"\\super 13\\nosupersub{}","plainCitation":"13","noteIndex":0},"citationItems":[{"id":75,"uris":[""],"uri":[""],"itemData":{"id":75,"type":"article-journal","title":"The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis","container-title":"The International Journal of Lower Extremity Wounds","page":"94-99","volume":"12","issue":"2","source":"PubMed","abstract":"Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 10(9)/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.","DOI":"10.1177/1534734613486152","ISSN":"1552-6941","note":"PMID: 23667102","journalAbbreviation":"Int J Low Extrem Wounds","language":"eng","author":[{"family":"Michail","given":"Marios"},{"family":"Jude","given":"Edward"},{"family":"Liaskos","given":"Christos"},{"family":"Karamagiolis","given":"Spyridon"},{"family":"Makrilakis","given":"Konstantinos"},{"family":"Dimitroulis","given":"Dimitrios"},{"family":"Michail","given":"Othon"},{"family":"Tentolouris","given":"Nicholas"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 13 and early prosthetic joint infections ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wWqz2xk7","properties":{"formattedCitation":"\\super 12\\nosupersub{}","plainCitation":"12","noteIndex":0},"citationItems":[{"id":96,"uris":[""],"uri":[""],"itemData":{"id":96,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein","container-title":"Australian Prescriber","page":"93-4","volume":"38","issue":"3","source":".au","abstract":"C-reactive protein is a better indicator of inflammation than the erythrocyte sedimentation rate. It is more sensitive and responds more quickly to changes in the clinical situation. False negative and false positive results are more common when measuring the erythrocyte sedimentation rate. Renal disease, female sex and older age increase the erythrocyte sedimentation rate.","DOI":"10.18773/austprescr.2015.034","language":"en","author":[{"family":"Harrison","given":"Michael"}],"issued":{"date-parts":[["2015",5,31]]}}}],"schema":""} 12).TestsCRP and ESR in British ColumbiaMSP Cost of Tests ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"B3ByZLIL","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":80,"uris":[""],"uri":[""],"itemData":{"id":80,"type":"webpage","title":"Laboratory Services Outpatient Payment Schedule - Province of British Columbia","abstract":"laboratory services outpatient payment schedule","URL":"","language":"eng","author":[{"family":"Health","given":"Ministry","dropping-particle":"of"}],"accessed":{"date-parts":[["2018",6,13]]}}}],"schema":""} 1ESR (fee item 90515) $10.61CRP/hsCRP (fee item 91300) $10.31Current to January 1st, 2018In BC the ESR will only be performed if a written indication is provided on the requisition. If both CRP and ESR are ordered, only CRP is payable. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ffsWyesy","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":80,"uris":[""],"uri":[""],"itemData":{"id":80,"type":"webpage","title":"Laboratory Services Outpatient Payment Schedule - Province of British Columbia","abstract":"laboratory services outpatient payment schedule","URL":"","language":"eng","author":[{"family":"Health","given":"Ministry","dropping-particle":"of"}],"accessed":{"date-parts":[["2018",6,13]]}}}],"schema":""} 1C-Reactive Protein (CRP)CRP is produced in the liver as part of the acute-phase response. It is directly measurable and responsive to changes in the inflammatory process, increasing rapidly during inflammation and decreasing quickly when the inflammation subsides. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a141qsrf3kf","properties":{"formattedCitation":"\\super 14\\nosupersub{}","plainCitation":"14","noteIndex":0},"citationItems":[{"id":105,"uris":[""],"uri":[""],"itemData":{"id":105,"type":"article-journal","title":"C-reactive protein: a critical update","container-title":"The Journal of Clinical Investigation","page":"1805-1812","volume":"111","issue":"12","source":"","DOI":"10.1172/JCI18921","ISSN":"0021-9738","note":"PMID: 12813013","shortTitle":"C-reactive protein","journalAbbreviation":"J Clin Invest","language":"en","author":[{"family":"Pepys","given":"Mark B."},{"family":"Hirschfield","given":"Gideon M."}],"issued":{"date-parts":[["2003",6,15]]}}}],"schema":""} 14CRP is ordered:During the diagnosis and monitoring of disease.To review a therapeutic approach in primary prevention of cardiovascular disease in patients assessed at intermediate risk. This is the only indication for CRP assessment in asymptomatic individuals.Elevated CRP values are found in a variety of pathological states and need to be considered along with other clinical findings. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mLUT2mXB","properties":{"formattedCitation":"\\super 15\\nosupersub{}","plainCitation":"15","noteIndex":0},"citationItems":[{"id":101,"uris":[""],"uri":[""],"itemData":{"id":101,"type":"article-journal","title":"Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine","container-title":"WMJ: official publication of the State Medical Society of Wisconsin","page":"317-321","volume":"115","issue":"6","source":"PubMed","abstract":"INTRODUCTION: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are widely used\nlaboratory markers of systemic inflammation.\nOBJECTIVE: A thorough understanding of the similarities and differences between these two serological\nmarkers, including factors that affect measurements, is necessary for the proper utilization\nand interpretation of ESR and CRP.\nMETHODS: This review summarizes the current published literature (searched on MEDLINE\nthrough February 2016) surrounding the history and utilization of ESR and CRP, and examines\nfactors that affect ESR and CRP measurements and discordance amongst these two inflammatory\nmarkers.\nRESULTS: As ESR and CRP lack sensitivity or specificity, these tests should be used only in combination\nwith clinical history and physical exam for diagnosis and monitoring of pathological conditions.\nThe clinical application of these tests in diagnosis is best applied to conditions in which\nthere is high or low clinical probability of disease. Importantly, discrepancies between ESR and\nCRP measurements commonly have been reported in both inpatient and outpatient settings and\nthis problem may be particularly prevalent in chronic inflammatory diseases. Numerous physiological\nfactors, including noninfectious conditions and resolution of inflammation can contribute\nto abnormally high ESR/low CRP readings or vice versa.\nCONCLUSIONS: Although discordance may be encountered in certain settings, proper utilization of\nESR and CRP measurements continues to play an important role in clinical management of many\ninflammatory and other conditions.","ISSN":"1098-1861","note":"PMID: 29094869","journalAbbreviation":"WMJ","language":"eng","author":[{"family":"Bray","given":"Christopher"},{"family":"Bell","given":"Lauren N."},{"family":"Liang","given":"Hong"},{"family":"Haykal","given":"Rasha"},{"family":"Kaiksow","given":"Farah"},{"family":"Mazza","given":"Joseph J."},{"family":"Yale","given":"Steven H."}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} 15 If the clinical history and physical findings are suggestive of specific disease processes, other investigations are usually more appropriate.All CRP assays measure the same protein. High sensitivity (hs) CRP is a designation given to laboratory assays able to measure CRP levels below 5 mg/L. Laboratories reporting CRP values less than 5 mg/L are using an hsCRP assay. CRP and hsCRP perform equally well for the diagnosis and monitoring of infectious and other inflammatory conditions. CRP assays measuring below 5 mg/L (hsCRP) can be used to stratify patients for cardiovascular disease risk.Inflammation and InfectionWithin the appropriate clinical context, CRP levels above 5 mg/L can help support the diagnosis of an inflammatory or infectious process. However, CRP levels less than 5 mg/L do not rule out an inflammatory or infectious process.CRP may be used to evaluate patients with unexplained symptoms or a deterioration of health status when:an inflammatory or infectious disease is suspected; anda specific diagnosis is not made effectively by other meansCRP may be used to monitor the activity of temporal (giant cell) arteritis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6pmDteUv","properties":{"formattedCitation":"\\super 2\\uc0\\u8211{}4\\nosupersub{}","plainCitation":"2–4","noteIndex":0},"citationItems":[{"id":104,"uris":[""],"uri":[""],"itemData":{"id":104,"type":"article-journal","title":"Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria","container-title":"American Journal of Ophthalmology","page":"285-296","volume":"123","issue":"3","source":"ScienceDirect","abstract":"Purpose\nTo ascertain the validity, reliability, sensitivity, and specificity of various signs and symptoms of and diagnostic tests for early diagnosis of giant cell arteritis.\nMethods\nFrom 1973 to 1994, we studied 363 patients who had temporal artery biopsy for suspected giant cell arteritis. All patients underwent detailed clinical evaluation and had erythrocyte sedimentation rates determined; since 1985, 223 patients had their C-reactive protein values estimated. Erythrocyte sedimentation rate and C-reactive protein levels were also estimated in 749 and 138 control subjects, respectively. Signs and symptoms of giant cell arteritis, erythrocyte sedimentation rate, and C-reactive protein levels among patients with positive and negative biopsies were compared.\nResults\nOf the 363 patients, temporal artery biopsy was positive in 106 and negative in 257. The odds of a positive biopsy were 9.0 times greater with jaw claudication (P < .0001), 3.4 times greater with neck pain (P = .0085), 2.0 times greater with an erythrocyte sedimentation rate of 47 to 107 mm/hour (P = .0454), 3.2 times greater with C-reactive protein above 2.45 mg/dl (P = .0208), and 2.0 times greater for age 75 years or more (P = .0105).\nConclusions\nClinical criteria most strongly suggestive of giant cell arteritis include jaw claudication, C-reactive protein above 2.45 mg/dl, neck pain, and an erythrocyte sedimentation rate of 47 mm/hour or more, in that order. C-reactive protein was more sensitive (100%) than erythrocyte sedimentation rate (92%) for detection of giant cell arteritis; erythrocyte sedimentation rate combined with C-reactive protein gave the best specificity (97%).","DOI":"10.1016/S0002-9394(14)70123-0","ISSN":"0002-9394","shortTitle":"Giant Cell Arteritis","journalAbbreviation":"American Journal of Ophthalmology","author":[{"family":"Hayreh","given":"SOHAN SINGH"},{"family":"Podhajsky","given":"PATRICIA A."},{"family":"Raman","given":"REMA"},{"family":"Zimmerman","given":"BRIDGET"}],"issued":{"date-parts":[["1997",3,1]]}}},{"id":103,"uris":[""],"uri":[""],"itemData":{"id":103,"type":"article-journal","title":"Giant Cell Arteritis: Laboratory Predictors of a Positive Temporal Artery Biopsy","container-title":"Ophthalmology","page":"1201-1204","volume":"118","issue":"6","source":"ScienceDirect","abstract":"Purpose\nTo identify laboratory predictors of a positive temporal artery biopsy.\nDesign\nCross-sectional study using retrospective electronic data base review.\nParticipants\nThere were 3001 patients who had a temporal artery biopsy.\nMethods\nThe electronic database of a large health maintenance organization was searched for all patients who had a temporal artery biopsy performed from 1997 to 2006.\nMain Outcome Measures\nOdds ratios for erythrocyte sedimentation rate, C-reactive protein (CRP), and platelet count values associated with a positive temporal artery biopsy.\nResults\nFour hundred fifty-nine cases of biopsy-proven giant cell arteritis were identified. The odds of a positive biopsy were 1.5 times greater with an erythrocyte sedimentation rate of 47 to 107 mm/hr, 5.3 times greater with a CRP >2.45 mg/dL, and 4.2 times greater with platelets >400 000/μL.\nConclusions\nIn this largest population-based giant cell arteritis study in the United States to date, we reaffirm Hayreh's finding of the significance of a CRP level >2.45 mg/dL in predicting a positive biopsy. Our findings support the literature suggesting that CRP and thrombocytosis may be stronger predictors of positive biopsy than erythrocyte sedimentation rate.\nFinancial Disclosure(s)\nThe authors have no proprietary or commercial interest in any of the materials discussed in this article.","DOI":"10.1016/j.ophtha.2010.10.002","ISSN":"0161-6420","shortTitle":"Giant Cell Arteritis","journalAbbreviation":"Ophthalmology","author":[{"family":"Walvick","given":"Matthew D."},{"family":"Walvick","given":"Michael P."}],"issued":{"date-parts":[["2011",6,1]]}}},{"id":102,"uris":[""],"uri":[""],"itemData":{"id":102,"type":"article-journal","title":"Utility of Erythrocyte Sedimentation Rate and C-Reactive Protein for the Diagnosis of Giant Cell Arteritis","container-title":"Seminars in Arthritis and Rheumatism","page":"866-871","volume":"41","issue":"6","source":"PubMed Central","abstract":"Objectives\n1) To evaluate the utility of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for the diagnosis of giant cell arteritis (GCA) 2) to determine the frequency of normal ESR and CRP at diagnosis of GCA.\n\nMethods\nAll patients undergoing temporal artery biopsy (TAB) between 2000 and 2008 were identified. Only subjects with both ESR and CRP at the time of TAB were included. The medical records of all patients were reviewed.\n\nResults\nWe included 764 patients (65% women), mean age 72.7 (±9.27) years, who underwent TAB. Biopsy was consistent with GCA in 177 patients (23%). Elevated CRP and elevated ESR provided a sensitivity of 86.9% and 84.1% respectively, for a positive TAB. The odds ratio (OR) of a concordantly elevated ESR and CRP for positive TAB was 3.06 (95% CI 2.03, 4.62) while the OR for concordantly normal ESR and CRP was 0.49 (95% CI 0.29, 0.83)., Seven patients (4%) with a positive TAB for GCA had a normal ESR and CRP at diagnosis. Compared to GCA patients with elevated markers of inflammation, a greater proportion of these patients had polymyalgia rheumatica symptoms (p=0.008) while constitutional symptoms, anemia and thrombocytosis were observed less often (p<0.05).\n\nConclusions\nCRP is a more sensitive marker than ESR for a positive TAB that is diagnostic of GCA. There may be clinical utility in obtaining both tests in the evaluation of patients with suspected GCA. A small proportion of patients with GCA may have normal inflammatory markers at diagnosis.","DOI":"10.1016/j.semarthrit.2011.10.005","ISSN":"0049-0172","note":"PMID: 22119103\nPMCID: PMC3307891","journalAbbreviation":"Semin Arthritis Rheum","author":[{"family":"Kermani","given":"Tanaz A."},{"family":"Schmidt","given":"Jean"},{"family":"Crowson","given":"Cynthia S."},{"family":"Ytterberg","given":"Steven R."},{"family":"Hunder","given":"Gene G."},{"family":"Matteson","given":"Eric L."},{"family":"Warrington","given":"Kenneth J."}],"issued":{"date-parts":[["2012",6]]}}}],"schema":""} 2–4, polymyalgia rheumatica ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0cdNj0UO","properties":{"formattedCitation":"\\super 5,6\\nosupersub{}","plainCitation":"5,6","noteIndex":0},"citationItems":[{"id":95,"uris":[""],"uri":[""],"itemData":{"id":95,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica: a prospective follow-up study","container-title":"Seminars in Arthritis and Rheumatism","page":"17-24","volume":"30","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To determine the frequency and clinical features of patients with polymyalgia rheumatica (PMR) and normal erythrocyte sedimentation rate (ESR) at diagnosis or during relapse/recurrence. To evaluate the usefulness of C-reactive protein (CRP) and ESR in the assessment of PMR activity.\nMETHODS: A prospective follow-up study on 177 consecutive patients meeting the criteria for PMR diagnosed over a 5-year period was conducted in two Italian secondary referral centers of rheumatology. At diagnosis and during follow-up, ESR (Westergren method) and CRP (nephelometry) were measured in all patients. Phenotypic analysis of lymphocyte subpopulations was performed on 78 PMR patients at diagnosis. A two-color technique using the association of specific monoclonal antibodies was applied. A control group consisting of 18 healthy adults older than 60 years was matched for age and sex with the PMR patients.\nRESULTS: Ten of 177 (6%) patients had normal ESR values at diagnosis (< or = 30 mm/h). Patients with normal ESR were predominantly men and had lower CRP levels; systemic signs and symptoms were more frequent in patients with higher ESR. The percentages of circulating CD8+ cells were similar in the two groups. CRP values at diagnosis were normal in only 2 of 177 (1%) patients. CRP values were elevated in 9 of 10 patients with normal ESR at diagnosis. Twenty-five episodes of relapse/recurrence with normal ESR occurred in 17 patients. CRP was high in 62% of these episodes. Results of univariate analysis indicated that the 10th percentile for ESR (40 mm/h) and the 70th percentile for CRP (7.8 mg/dL) values at diagnosis were the best cutoff points that discriminate between patients with and without relapse/recurrence. Cox proportional hazards modeling showed that ESR greater than 40 mm/h and CRP greater than 7.8 mg/dL at diagnosis were the two variables that independently increased the risk of relapse/recurrence. However, the relative risk related to ESR was twice than that related to CRP (4.9 vs 2.1).\nCONCLUSION: PMR with a normal ESR at diagnosis was infrequent in our study compared with previous studies. ESR was a superior predictor of relapse than CRP. However, CRP was a more sensitive indicator of current disease activity.","DOI":"10.1053/sarh.2000.8366","ISSN":"0049-0172","note":"PMID: 10966209","shortTitle":"Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica","journalAbbreviation":"Semin. Arthritis Rheum.","language":"eng","author":[{"family":"Cantini","given":"F."},{"family":"Salvarani","given":"C."},{"family":"Olivieri","given":"I."},{"family":"Macchioni","given":"L."},{"family":"Ranzi","given":"A."},{"family":"Niccoli","given":"L."},{"family":"Padula","given":"A."},{"family":"Boiardi","given":"L."}],"issued":{"date-parts":[["2000",8]]}}},{"id":94,"uris":[""],"uri":[""],"itemData":{"id":94,"type":"article-journal","title":"Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study","container-title":"Arthritis and Rheumatism","page":"33-38","volume":"53","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To determine laboratory parameters that may be useful in identifying polymyalgia rheumatica (PMR) patients who require long-term corticosteroid therapy.\nMETHODS: A prospective followup study of 94 consecutive untreated patients with PMR were assessed for relapse/recurrence for a mean of 39 months. This cohort represented all the patients diagnosed over a 4-year period in 2 Italian secondary referral centers. Patients were monitored for clinical signs and symptoms, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum interleukin-6 (IL-6). IL-6 levels were also measured in 43 controls matched to the patients for age and sex.\nRESULTS: The ESR was elevated in 91.5% of the patients prior to therapy initiation, as were CRP in 98.9% and serum IL-6 in 92.6%. Forty-seven (50.0%) patients had at least 1 relapse/recurrence during the followup period and 24 (25.5%) had at least 2. After 4 weeks of prednisone therapy, ESR was elevated in 13.2% patients, CRP in 41.9%, and serum IL-6 in 37.2%. IL-6 levels remained persistently elevated in 9.9% and CRP in 8.7% of patients during the first year of followup, whereas no patient had persistently elevated ESR. Persistently elevated CRP and IL-6 levels were significantly associated with an increased risk of relapse/recurrence. In particular, patients with persistently elevated levels of IL-6 during the first year of therapy had the highest relative risk.\nCONCLUSION: Despite the control of clinical symptoms, corticosteroids do not adequately control the inflammatory process in a subset of patients with PMR who have persistently elevated levels of CRP and IL-6 and who have a higher risk of relapsing.","DOI":"10.1002/art.20901","ISSN":"0004-3591","note":"PMID: 15696567","shortTitle":"Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica","journalAbbreviation":"Arthritis Rheum.","language":"eng","author":[{"family":"Salvarani","given":"Carlo"},{"family":"Cantini","given":"Fabrizio"},{"family":"Niccoli","given":"Laura"},{"family":"Macchioni","given":"Pierluigi"},{"family":"Consonni","given":"Dario"},{"family":"Bajocchi","given":"Gianluigi"},{"family":"Vinceti","given":"Marco"},{"family":"Catanoso","given":"Maria Grazia"},{"family":"Pulsatelli","given":"Lia"},{"family":"Meliconi","given":"Riccardo"},{"family":"Boiardi","given":"Luigi"}],"issued":{"date-parts":[["2005",2,15]]}}}],"schema":""} 5,6, inflammatory arthritis (e.g. rheumatoid arthritis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kJ2E7NGa","properties":{"formattedCitation":"\\super 7,8\\nosupersub{}","plainCitation":"7,8","noteIndex":0},"citationItems":[{"id":89,"uris":[""],"uri":[""],"itemData":{"id":89,"type":"article-journal","title":"Which measure of inflammation to use? A comparison of erythrocyte sedimentation rate and C-reactive protein measurements from randomized clinical trials of golimumab in rheumatoid arthritis","container-title":"The Journal of Rheumatology","page":"1606-1610","volume":"36","issue":"8","source":"PubMed","abstract":"OBJECTIVE: To assess clinical utility of measurements of C-reactive protein (CRP) versus Westergren erythrocyte sedimentation rate (ESR) in evaluating patients with rheumatoid arthritis (RA).\nMETHODS: Data from 3 randomized clinical trials of golimumab involving 1247 patients with RA in which ESR and CRP were obtained at baseline and Week 24, along with standard measures of clinical disease activity [swollen and tender joint counts, global disease activity assessment, composite Disease Activity Scores (DAS) and Clinical Disease Activity Index (CDAI)], were utilized. Result. Both ESR and CRP were significant predictors of swollen joint count (p < 0.001 for each). Only 4.5% of patients with no swollen joints had elevated CRP and normal ESR, but 15.2% had elevated ESR and normal CRP. ESR and CRP correlated significantly (Pearson r = 0.59, p < 0.001) with each other. DAS-ESR and DAS-CRP were highly correlated (r = 0.96, p < 0.001) with each other, although DAS-ESR values were slightly lower than the DAS-CRP values at the upper end of the range (DAS > 8). Both ESR and CRP were significantly associated with CDAI (p < 0.001 for each).\nCONCLUSION: It is not necessary to obtain both ESR and CRP measures for clinical disease activity assessment in clinical trials of RA. Neither test adds significantly to clinical measures of disease activity including joint counts and global assessments. Where available, the CRP alone may be preferred for disease activity assessment as a simple, validated, reproducible, non age-dependent test.","DOI":"10.3899/jrheum.081188","ISSN":"0315-162X","note":"PMID: 19531760","shortTitle":"Which measure of inflammation to use?","journalAbbreviation":"J. Rheumatol.","language":"eng","author":[{"family":"Crowson","given":"Cynthia S."},{"family":"Rahman","given":"Mahboob U."},{"family":"Matteson","given":"Eric L."}],"issued":{"date-parts":[["2009",8]]}}},{"id":76,"uris":[""],"uri":[""],"itemData":{"id":76,"type":"webpage","title":"NRAS - National Rheumatoid Arthritis Society","URL":"","accessed":{"date-parts":[["2018",7,31]]}}}],"schema":""} 7,8 and SLE ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tLBh36oG","properties":{"unsorted":true,"formattedCitation":"\\super 9,10\\nosupersub{}","plainCitation":"9,10","noteIndex":0},"citationItems":[{"id":72,"uris":[""],"uri":[""],"itemData":{"id":72,"type":"article-journal","title":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity","container-title":"Clinical Rheumatology","page":"1835-1844","volume":"37","issue":"7","source":"PubMed","abstract":"To examine disease activity parameters in patients with systemic lupus erythematosus (SLE) experiencing flare, infection, both, or neither condition, focusing on erythrocyte sedimentation rate (ESR). This study is a retrospective analysis of 371 consecutive inpatient SLE cases from 2006 to 2015. Cases were classified as flare (n?=?147), infection (n?=?48), both (n?=?23), or neither (n?=?135). ESR levels were correlated to C-reactive protein (CRP), ferritin, anti-dsDNA antibodies, complement C3 reduction, serositis, and erythrocyturia with proteinuria (Pearson's correlation). ESR levels were related to an age- and gender-adapted cut-off value (ESRp). We analyzed mean values of age, ESR, ESRp, CRP, ferritin and distribution of anti-dsDNA antibodies, C3 reduction, serositis, and erythrocyturia with proteinuria. Sensitivity and specificity were calculated via receiver operating characteristic or two-by-two table. Association of parameters with disease activity and infection was tested via two-sided chi square test. ESR correlated moderately with CRP in cases with flare and/or infection (r?=?0.505-0.586). While ESR and CRP were normal in remission, mean values overlapped in cases with flare, infection, or both. ESRp was higher in flare than in infection (p?=?0.048). ESR lost association to activity in infected cases, CRP to infection in flaring cases. ESRp, serositis, and anti-dsDNA antibodies were related to disease activity regardless of infections. Anti-dsDNA antibodies were most sensitive for detecting flares (74%), while serositis, proteinuria with erythrocyturia, anti-dsDNA antibodies, C3 reduction, and ESRp values ≥?2 were most specific. ESR levels were raised by flares, infections, and age; adapting them to age and gender increased their diagnostic value. Obtaining several parameters remains necessary to differentiate flare from infection.","DOI":"10.1007/s10067-018-4093-3","ISSN":"1434-9949","note":"PMID: 29656375","shortTitle":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus?","journalAbbreviation":"Clin. Rheumatol.","language":"eng","author":[{"family":"Sch?fer","given":"Valentin Sebastian"},{"family":"Wei?","given":"Katharina"},{"family":"Krause","given":"Andreas"},{"family":"Schmidt","given":"Wolfgang Andreas"}],"issued":{"date-parts":[["2018",7]]}}},{"id":77,"uris":[""],"uri":[""],"itemData":{"id":77,"type":"article-journal","title":"The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults","container-title":"Rheumatology","page":"e1-e45","volume":"57","issue":"1","source":"academic.","DOI":"10.1093/rheumatology/kex286","ISSN":"1462-0324","journalAbbreviation":"Rheumatology (Oxford)","language":"en","author":[{"family":"Gordon","given":"Caroline"},{"family":"Amissah-Arthur","given":"Maame-Boatemaa"},{"family":"Gayed","given":"Mary"},{"family":"Brown","given":"Sue"},{"family":"Bruce","given":"Ian N."},{"family":"D’Cruz","given":"David"},{"family":"Empson","given":"Benjamin"},{"family":"Griffiths","given":"Bridget"},{"family":"Jayne","given":"David"},{"family":"Khamashta","given":"Munther"},{"family":"Lightstone","given":"Liz"},{"family":"Norton","given":"Peter"},{"family":"Norton","given":"Yvonne"},{"family":"Schreiber","given":"Karen"},{"family":"Isenberg","given":"David"}],"issued":{"date-parts":[["2018",1,1]]}}}],"schema":""} 9,10) and inflammatory bowel disease. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Zun1GIUH","properties":{"formattedCitation":"\\super 11\\nosupersub{}","plainCitation":"11","noteIndex":0},"citationItems":[{"id":78,"uris":[""],"uri":[""],"itemData":{"id":78,"type":"article-journal","title":"C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis","container-title":"The American Journal of Gastroenterology","page":"802-819; quiz 820","volume":"110","issue":"6","source":"PubMed","abstract":"OBJECTIVES: Persistent disease activity is associated with a poor prognosis in inflammatory bowel disease (IBD). Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a treatment concept. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity is a priority. The objective was to evaluate the diagnostic accuracy of C-reactive protein (CRP), fecal calprotectin (FC), and stool lactoferrin (SL) for assessment of endoscopically defined disease activity in IBD.\nMETHODS: Databases were searched from inception to November 6, 2014 for relevant cohort and case-control studies that evaluated the diagnostic accuracy of CRP, FC, or SL and used endoscopy as a gold standard in patients with symptoms consistent with active IBD. Sensitivities and specificities were pooled to generate operating property estimates for each test using a bivariate diagnostic meta-analysis.\nRESULTS: Nineteen studies (n=2499 patients) were eligible. The pooled sensitivity and specificity estimates for CRP, FC, and SL were 0.49 (95% confidence interval (CI) 0.34-0.64) and 0.92 (95% CI 0.72-0.96), 0.88 (95% CI 0.84-0.90) and 0.73 (95% CI 0.66-0.79), and 0.82 (95% CI 0.73-0.88) and 0.79 (95% CI 0.62-0.89), respectively. FC was more sensitive than CRP in both diseases and was more sensitive in ulcerative colitis than Crohn's disease.\nCONCLUSIONS: Although CRP, FC, and SL are useful biomarkers, their value in managing individual patients must be considered in specific clinical contexts.","DOI":"10.1038/ajg.2015.120","ISSN":"1572-0241","note":"PMID: 25964225","shortTitle":"C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients","journalAbbreviation":"Am. J. Gastroenterol.","language":"eng","author":[{"family":"Mosli","given":"Mahmoud H."},{"family":"Zou","given":"Guangyong"},{"family":"Garg","given":"Sushil K."},{"family":"Feagan","given":"Sean G."},{"family":"MacDonald","given":"John K."},{"family":"Chande","given":"Nilesh"},{"family":"Sandborn","given":"William J."},{"family":"Feagan","given":"Brian G."}],"issued":{"date-parts":[["2015",6]]}}}],"schema":""} 11 For the vast majority of infections, repeat CRP is not indicated and assessment should be made on clinical grounds (e.g. cellulitis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dTcEJGYU","properties":{"formattedCitation":"\\super 16\\nosupersub{}","plainCitation":"16","noteIndex":0},"citationItems":[{"id":59,"uris":[""],"uri":[""],"itemData":{"id":59,"type":"article-journal","title":"Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital","container-title":"The Journal of Infection","page":"383-389","volume":"51","issue":"5","source":"PubMed","abstract":"Patients hospitalized in the authors' institution for erysipelas or cellulitis between January 1995 and December 2002 were included in this retrospective review. Two hundred cases of soft tissue infections were hospitalized during the study period. The mean age of the patients was 58 years. The most commonly involved site was the leg (66%), followed by the arm (24%) and face (6%). Most patients (71%) had a recognized risk factor for soft tissue infection. Fever was present in 71% of cases, with a mean duration of 3 days. Blood cultures were positive in 3 out of 141 (2%) cases, whereas cutaneous swabs were positive in 73 out of 92 (79%) cases. On admission, white blood cells counts (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels were elevated above normal levels in 100 out of 191 (50%) cases, 151 out of 176 (85%) cases, and 150 out of 154 (97%) cases, respectively. Patients with a hospital stay of more than 10 days had significantly higher CRP and ESR values than patients hospitalized for 10 days or less (P<0.01). A single antibiotic was used as treatment in 115 cases, whereas in the remaining 85 cases a combination of two antibiotics was administered. The most commonly used antibiotics were amoxicillin-clavulanic acid as single agent and penicillin with clindamycin as combination therapy. The mean duration of hospitalization was 7 days for patients treated with a single antibiotic and 11 days for patients treated with an antibiotic combination. A recurrence of infection occurred in 34 (17%) patients. Soft tissue infections are common and have a high degree of morbidity and require prolonged hospitalization and antibiotic treatment. Microbiological diagnosis is difficult and treatment is based on empiric evidence. ESR and CPR levels on admission may predict the severity of the disease and duration of hospitalization.","DOI":"10.1016/j.jinf.2004.12.010","ISSN":"1532-2742","note":"PMID: 16321649","shortTitle":"Erysipelas and cellulitis","journalAbbreviation":"J. Infect.","language":"eng","author":[{"family":"Lazzarini","given":"Luca"},{"family":"Conti","given":"Emma"},{"family":"Tositti","given":"Giulia"},{"family":"Lalla","given":"Fausto","non-dropping-particle":"de"}],"issued":{"date-parts":[["2005",12]]}}}],"schema":""} 16). Monitoring CRP levels may be useful in infections which require long term antibiotics (e.g. osteomyelitis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"c51sIQNi","properties":{"formattedCitation":"\\super 17\\nosupersub{}","plainCitation":"17","noteIndex":0},"citationItems":[{"id":58,"uris":[""],"uri":[""],"itemData":{"id":58,"type":"article-journal","title":"The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis","container-title":"International Wound Journal","page":"40-45","volume":"14","issue":"1","source":"PubMed","abstract":"In this study, we assessed the effectiveness of inflammatory markers to diagnose and monitor the treatment of osteomyelitis in the diabetic foot. We evaluated 35 consecutive patients admitted to our hospital with infected foot ulcers. Patients were divided in two groups based on the results of bone culture and histopathology: osteomyelitis and no osteomyelitis. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor alpha (TNFα), monocyte chemotactic protein-1 (MCP-1) and macrophage inflammatory protein-1 alpha (MIP1α) were measured at baseline after 3 and 6 weeks of standard therapy. PCT levels in the osteomyelitis group were significantly higher at baseline than in the group with no osteomyelitis (P = 0·049). There were no significant differences between the two groups in the levels of the other markers. CRP, ESR, PCT and IL-6 levels significantly declined in the group with osteomyelitis after starting therapy, while MCP-1 increased (P = 0·002). TNFα and MIP1α levels were below range in 80 out of 97 samples and therefore not reported. Our results suggest that PCT might be useful to distinguish osteomyelitis in infected foot ulcers. CRP, ESR, PCT and IL-6 are valuable when monitoring the effect of therapy.","DOI":"10.1111/iwj.12545","ISSN":"1742-481X","note":"PMID: 26634954","journalAbbreviation":"Int Wound J","language":"eng","author":[{"family":"Van Asten","given":"Suzanne Av"},{"family":"Nichols","given":"Adam"},{"family":"La Fontaine","given":"Javier"},{"family":"Bhavan","given":"Kavita"},{"family":"Peters","given":"Edgar Jg"},{"family":"Lavery","given":"Lawrence A."}],"issued":{"date-parts":[["2017",2]]}}}],"schema":""} 17).hsCRP and Cardiovascular Disease (CVD)When a patient without clinical cardiovascular disease is found to be at intermediate risk for CVD based on their Framingham Risk Score, hsCRP can be used as one of the secondary assessments to raise or lower their estimated cardiovascular risk (see the associated BC guideline resource Cardiovascular Disease – Primary Prevention: Resource Guide for Physicians). Patients at moderate cardiovascular risk who have an hsCRP >2mg/L (and typically < 5 mg/L) may benefit from statin therapy. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gkRhfGeu","properties":{"formattedCitation":"\\super 18,19\\nosupersub{}","plainCitation":"18,19","noteIndex":0},"citationItems":[{"id":100,"uris":[""],"uri":[""],"itemData":{"id":100,"type":"article-journal","title":"Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein","container-title":"The New England Journal of Medicine","page":"2195-2207","volume":"359","issue":"21","source":"PubMed","abstract":"BACKGROUND: Increased levels of the inflammatory biomarker high-sensitivity C-reactive protein predict cardiovascular events. Since statins lower levels of high-sensitivity C-reactive protein as well as cholesterol, we hypothesized that people with elevated high-sensitivity C-reactive protein levels but without hyperlipidemia might benefit from statin treatment.\nMETHODS: We randomly assigned 17,802 apparently healthy men and women with low-density lipoprotein (LDL) cholesterol levels of less than 130 mg per deciliter (3.4 mmol per liter) and high-sensitivity C-reactive protein levels of 2.0 mg per liter or higher to rosuvastatin, 20 mg daily, or placebo and followed them for the occurrence of the combined primary end point of myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes.\nRESULTS: The trial was stopped after a median follow-up of 1.9 years (maximum, 5.0). Rosuvastatin reduced LDL cholesterol levels by 50% and high-sensitivity C-reactive protein levels by 37%. The rates of the primary end point were 0.77 and 1.36 per 100 person-years of follow-up in the rosuvastatin and placebo groups, respectively (hazard ratio for rosuvastatin, 0.56; 95% confidence interval [CI], 0.46 to 0.69; P<0.00001), with corresponding rates of 0.17 and 0.37 for myocardial infarction (hazard ratio, 0.46; 95% CI, 0.30 to 0.70; P=0.0002), 0.18 and 0.34 for stroke (hazard ratio, 0.52; 95% CI, 0.34 to 0.79; P=0.002), 0.41 and 0.77 for revascularization or unstable angina (hazard ratio, 0.53; 95% CI, 0.40 to 0.70; P<0.00001), 0.45 and 0.85 for the combined end point of myocardial infarction, stroke, or death from cardiovascular causes (hazard ratio, 0.53; 95% CI, 0.40 to 0.69; P<0.00001), and 1.00 and 1.25 for death from any cause (hazard ratio, 0.80; 95% CI, 0.67 to 0.97; P=0.02). Consistent effects were observed in all subgroups evaluated. The rosuvastatin group did not have a significant increase in myopathy or cancer but did have a higher incidence of physician-reported diabetes.\nCONCLUSIONS: In this trial of apparently healthy persons without hyperlipidemia but with elevated high-sensitivity C-reactive protein levels, rosuvastatin significantly reduced the incidence of major cardiovascular events. ( number, NCT00239681.)","DOI":"10.1056/NEJMoa0807646","ISSN":"1533-4406","note":"PMID: 18997196","journalAbbreviation":"N. Engl. J. Med.","language":"eng","author":[{"family":"Ridker","given":"Paul M."},{"family":"Danielson","given":"Eleanor"},{"family":"Fonseca","given":"Francisco A. H."},{"family":"Genest","given":"Jacques"},{"family":"Gotto","given":"Antonio M."},{"family":"Kastelein","given":"John J. P."},{"family":"Koenig","given":"Wolfgang"},{"family":"Libby","given":"Peter"},{"family":"Lorenzatti","given":"Alberto J."},{"family":"MacFadyen","given":"Jean G."},{"family":"Nordestgaard","given":"B?rge G."},{"family":"Shepherd","given":"James"},{"family":"Willerson","given":"James T."},{"family":"Glynn","given":"Robert J."},{"literal":"JUPITER Study Group"}],"issued":{"date-parts":[["2008",11,20]]}}},{"id":99,"uris":[""],"uri":[""],"itemData":{"id":99,"type":"article-journal","title":"2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult","container-title":"Canadian Journal of Cardiology","page":"1263-1282","volume":"32","issue":"11","source":"onlinecjc.ca","DOI":"10.1016/j.cjca.2016.07.510","ISSN":"0828-282X, 1916-7075","journalAbbreviation":"Canadian Journal of Cardiology","language":"English","author":[{"family":"Anderson","given":"Todd J."},{"family":"Grégoire","given":"Jean"},{"family":"Pearson","given":"Glen J."},{"family":"Barry","given":"Arden R."},{"family":"Couture","given":"Patrick"},{"family":"Dawes","given":"Martin"},{"family":"Francis","given":"Gordon A."},{"family":"Genest","given":"Jacques"},{"family":"Grover","given":"Steven"},{"family":"Gupta","given":"Milan"},{"family":"Hegele","given":"Robert A."},{"family":"Lau","given":"David C."},{"family":"Leiter","given":"Lawrence A."},{"family":"Lonn","given":"Eva"},{"family":"Mancini","given":"G. B. John"},{"family":"McPherson","given":"Ruth"},{"family":"Ngui","given":"Daniel"},{"family":"Poirier","given":"Paul"},{"family":"Sievenpiper","given":"John L."},{"family":"Stone","given":"James A."},{"family":"Thanassoulis","given":"George"},{"family":"Ward","given":"Richard"}],"issued":{"date-parts":[["2016",11,1]]}}}],"schema":""} 18,19Erythrocyte Sedimentation Rate (ESR)CRP, rather than ESR, should be ordered to support the diagnosis of infectious or inflammatory conditions. There is no indication for ordering ESR when CRP is elevated.In the appropriate clinical context, if CRP is normal, ESR may provide useful information when:Used in combination with other biomarkers in monitoring SLE or other rheumatic conditions where patients do not mount a CRP response. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"30km8eMh","properties":{"unsorted":true,"formattedCitation":"\\super 9,10,12\\nosupersub{}","plainCitation":"9,10,12","noteIndex":0},"citationItems":[{"id":72,"uris":[""],"uri":[""],"itemData":{"id":72,"type":"article-journal","title":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity","container-title":"Clinical Rheumatology","page":"1835-1844","volume":"37","issue":"7","source":"PubMed","abstract":"To examine disease activity parameters in patients with systemic lupus erythematosus (SLE) experiencing flare, infection, both, or neither condition, focusing on erythrocyte sedimentation rate (ESR). This study is a retrospective analysis of 371 consecutive inpatient SLE cases from 2006 to 2015. Cases were classified as flare (n?=?147), infection (n?=?48), both (n?=?23), or neither (n?=?135). ESR levels were correlated to C-reactive protein (CRP), ferritin, anti-dsDNA antibodies, complement C3 reduction, serositis, and erythrocyturia with proteinuria (Pearson's correlation). ESR levels were related to an age- and gender-adapted cut-off value (ESRp). We analyzed mean values of age, ESR, ESRp, CRP, ferritin and distribution of anti-dsDNA antibodies, C3 reduction, serositis, and erythrocyturia with proteinuria. Sensitivity and specificity were calculated via receiver operating characteristic or two-by-two table. Association of parameters with disease activity and infection was tested via two-sided chi square test. ESR correlated moderately with CRP in cases with flare and/or infection (r?=?0.505-0.586). While ESR and CRP were normal in remission, mean values overlapped in cases with flare, infection, or both. ESRp was higher in flare than in infection (p?=?0.048). ESR lost association to activity in infected cases, CRP to infection in flaring cases. ESRp, serositis, and anti-dsDNA antibodies were related to disease activity regardless of infections. Anti-dsDNA antibodies were most sensitive for detecting flares (74%), while serositis, proteinuria with erythrocyturia, anti-dsDNA antibodies, C3 reduction, and ESRp values ≥?2 were most specific. ESR levels were raised by flares, infections, and age; adapting them to age and gender increased their diagnostic value. Obtaining several parameters remains necessary to differentiate flare from infection.","DOI":"10.1007/s10067-018-4093-3","ISSN":"1434-9949","note":"PMID: 29656375","shortTitle":"Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus?","journalAbbreviation":"Clin. Rheumatol.","language":"eng","author":[{"family":"Sch?fer","given":"Valentin Sebastian"},{"family":"Wei?","given":"Katharina"},{"family":"Krause","given":"Andreas"},{"family":"Schmidt","given":"Wolfgang Andreas"}],"issued":{"date-parts":[["2018",7]]}}},{"id":77,"uris":[""],"uri":[""],"itemData":{"id":77,"type":"article-journal","title":"The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults","container-title":"Rheumatology","page":"e1-e45","volume":"57","issue":"1","source":"academic.","DOI":"10.1093/rheumatology/kex286","ISSN":"1462-0324","journalAbbreviation":"Rheumatology (Oxford)","language":"en","author":[{"family":"Gordon","given":"Caroline"},{"family":"Amissah-Arthur","given":"Maame-Boatemaa"},{"family":"Gayed","given":"Mary"},{"family":"Brown","given":"Sue"},{"family":"Bruce","given":"Ian N."},{"family":"D’Cruz","given":"David"},{"family":"Empson","given":"Benjamin"},{"family":"Griffiths","given":"Bridget"},{"family":"Jayne","given":"David"},{"family":"Khamashta","given":"Munther"},{"family":"Lightstone","given":"Liz"},{"family":"Norton","given":"Peter"},{"family":"Norton","given":"Yvonne"},{"family":"Schreiber","given":"Karen"},{"family":"Isenberg","given":"David"}],"issued":{"date-parts":[["2018",1,1]]}}},{"id":96,"uris":[""],"uri":[""],"itemData":{"id":96,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein","container-title":"Australian Prescriber","page":"93-4","volume":"38","issue":"3","source":".au","abstract":"C-reactive protein is a better indicator of inflammation than the erythrocyte sedimentation rate. It is more sensitive and responds more quickly to changes in the clinical situation. False negative and false positive results are more common when measuring the erythrocyte sedimentation rate. Renal disease, female sex and older age increase the erythrocyte sedimentation rate.","DOI":"10.18773/austprescr.2015.034","language":"en","author":[{"family":"Harrison","given":"Michael"}],"issued":{"date-parts":[["2015",5,31]]}}}],"schema":""} 9,10,12Used in combination with other clinical tests when considering the possibility of low-grade bone and joint infections (e.g. osteomyelitis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IjGbAABp","properties":{"formattedCitation":"\\super 13\\nosupersub{}","plainCitation":"13","noteIndex":0},"citationItems":[{"id":75,"uris":[""],"uri":[""],"itemData":{"id":75,"type":"article-journal","title":"The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis","container-title":"The International Journal of Lower Extremity Wounds","page":"94-99","volume":"12","issue":"2","source":"PubMed","abstract":"Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 10(9)/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.","DOI":"10.1177/1534734613486152","ISSN":"1552-6941","note":"PMID: 23667102","journalAbbreviation":"Int J Low Extrem Wounds","language":"eng","author":[{"family":"Michail","given":"Marios"},{"family":"Jude","given":"Edward"},{"family":"Liaskos","given":"Christos"},{"family":"Karamagiolis","given":"Spyridon"},{"family":"Makrilakis","given":"Konstantinos"},{"family":"Dimitroulis","given":"Dimitrios"},{"family":"Michail","given":"Othon"},{"family":"Tentolouris","given":"Nicholas"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 13 and early prosthetic joint infections ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wYHKkuJw","properties":{"formattedCitation":"\\super 12\\nosupersub{}","plainCitation":"12","noteIndex":0},"citationItems":[{"id":96,"uris":[""],"uri":[""],"itemData":{"id":96,"type":"article-journal","title":"Erythrocyte sedimentation rate and C-reactive protein","container-title":"Australian Prescriber","page":"93-4","volume":"38","issue":"3","source":".au","abstract":"C-reactive protein is a better indicator of inflammation than the erythrocyte sedimentation rate. It is more sensitive and responds more quickly to changes in the clinical situation. False negative and false positive results are more common when measuring the erythrocyte sedimentation rate. Renal disease, female sex and older age increase the erythrocyte sedimentation rate.","DOI":"10.18773/austprescr.2015.034","language":"en","author":[{"family":"Harrison","given":"Michael"}],"issued":{"date-parts":[["2015",5,31]]}}}],"schema":""} 12).ResourcesPatient and Caregiver ResourcesHealthLinkBC.ca: C-reactive protein and HYPERLINK "" \l "abq4482"high sensitivity C-reactive proteinReferences ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1. Health M of. Laboratory Services Outpatient Payment Schedule - Province of British Columbia [Internet]. [cited 2018 Jun 13]. Available from: . Hayreh SS, Podhajsky PA, Raman R, Zimmerman B. Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria. Am J Ophthalmol. 1997 Mar 1;123(3):285–96. 3. Walvick MD, Walvick MP. Giant Cell Arteritis: Laboratory Predictors of a Positive Temporal Artery Biopsy. Ophthalmology. 2011 Jun 1;118(6):1201–4. 4. Kermani TA, Schmidt J, Crowson CS, Ytterberg SR, Hunder GG, Matteson EL, et al. Utility of Erythrocyte Sedimentation Rate and C-Reactive Protein for the Diagnosis of Giant Cell Arteritis. Semin Arthritis Rheum. 2012 Jun;41(6):866–71. 5. Cantini F, Salvarani C, Olivieri I, Macchioni L, Ranzi A, Niccoli L, et al. Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica: a prospective follow-up study. Semin Arthritis Rheum. 2000 Aug;30(1):17–24. 6. Salvarani C, Cantini F, Niccoli L, Macchioni P, Consonni D, Bajocchi G, et al. Acute-phase reactants and the risk of relapse/recurrence in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 2005 Feb 15;53(1):33–8. 7. Crowson CS, Rahman MU, Matteson EL. Which measure of inflammation to use? A comparison of erythrocyte sedimentation rate and C-reactive protein measurements from randomized clinical trials of golimumab in rheumatoid arthritis. J Rheumatol. 2009 Aug;36(8):1606–10. 8. NRAS - National Rheumatoid Arthritis Society [Internet]. [cited 2018 Jul 31]. Available from: . Sch?fer VS, Wei? K, Krause A, Schmidt WA. Does erythrocyte sedimentation rate reflect and discriminate flare from infection in systemic lupus erythematosus? Correlation with clinical and laboratory parameters of disease activity. Clin Rheumatol. 2018 Jul;37(7):1835–44. 10. Gordon C, Amissah-Arthur M-B, Gayed M, Brown S, Bruce IN, D’Cruz D, et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology. 2018 Jan 1;57(1):e1–45. 11. Mosli MH, Zou G, Garg SK, Feagan SG, MacDonald JK, Chande N, et al. C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis. Am J Gastroenterol. 2015 Jun;110(6):802–19; quiz 820. 12. Harrison M. Erythrocyte sedimentation rate and C-reactive protein. Aust Prescr. 2015 May 31;38(3):93–4. 13. Michail M, Jude E, Liaskos C, Karamagiolis S, Makrilakis K, Dimitroulis D, et al. The performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. Int J Low Extrem Wounds. 2013 Jun;12(2):94–9. 14. Pepys MB, Hirschfield GM. C-reactive protein: a critical update. J Clin Invest. 2003 Jun 15;111(12):1805–12. 15. Bray C, Bell LN, Liang H, Haykal R, Kaiksow F, Mazza JJ, et al. Erythrocyte Sedimentation Rate and C-reactive Protein Measurements and Their Relevance in Clinical Medicine. WMJ Off Publ State Med Soc Wis. 2016;115(6):317–21. 16. Lazzarini L, Conti E, Tositti G, de Lalla F. Erysipelas and cellulitis: clinical and microbiological spectrum in an Italian tertiary care hospital. J Infect. 2005 Dec;51(5):383–9. 17. Van Asten SA, Nichols A, La Fontaine J, Bhavan K, Peters EJ, Lavery LA. The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis. Int Wound J. 2017 Feb;14(1):40–5. 18. Ridker PM, Danielson E, Fonseca FAH, Genest J, Gotto AM, Kastelein JJP, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008 Nov 20;359(21):2195–207. 19. Anderson TJ, Grégoire J, Pearson GJ, Barry AR, Couture P, Dawes M, et al. 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol. 2016 Nov 1;32(11):1263–82. AbbreviationsCRPC-Reactive ProteinESRErythrocyte Sedimentation RatehsCRP High sensitivity C-Reactive ProteinSLE Systemic lupus erythematosusThis guideline is based on scientific evidence current as of the effective date.The guideline was developed by the Guidelines and Protocols Advisory Committee, approved by Doctors of BC and adopted by the Medical Services Commission.THE GUIDELINES AND PROTOCOLS ADVISORY COMMITTEEThe principles of the Guidelines and Protocols Advisory Committee are to:encourage appropriate responses to common medical situations recommend actions that are sufficient and efficient, neither excessive nor deficient permit exceptions when justified by clinical circumstances Contact Information:Guidelines and Protocols Advisory CommitteePO Box 9642 STN PROV GOVTVictoria, BC V8W 9P1Email: hlth.guidelines@gov.bc.ca Website: BCGuidelines.caDisclaimerThe Clinical Practice Guidelines (the guidelines) have been developed by the guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional. ................
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