BackgroundAvailability of powerful biological agents to treat rheumatoid arthritis (RA) has led to a strategy of treat-to-target toward remission or low disease activity according to a quantitative index, although higher levels of disease activity according to shared decisions are recognized as appropriate for certain patients.1 Substantial improvement in patient status was documented quantitatively in 2000 compared to 1985,2 maintained in 20083 and 20104, but few reports in recent years compare patient status in routine care to earlier data.ObjectivesTo analyze post-2010 reports concerning mean or median or categories of DAS28, CDAI, and RAPID3 to depict patient status, and compared to pre-2011 reports.MethodsPubMed searches were conducted for 2011-2021 reports for “DAS28 (disease activity score) categories not trial,” and repeated twice, replacing “DAS28” with “CDAI” (clinical disease activity index) and “RAPID3” (routine assessment of patient index data). Activity/severity levels for high, moderate, low, and remission, respectively, are: DAS28 (0-10) >5.1, 3.2–5.1, 2.6–3.2, ≤2.6; CDAI (0-76) >22, 10.1–22, 2.9-10, ≤2.8; RAPID3 (0-30) >12, 6.1–12, 3.1-6, ≤3.0. Mean and/or median DAS28, CDAI, or RAPID3, and/or proportions of patients who were in remission, low, moderate, and high activity/severity were compiled. Results were compared to 3 pre-2011 reports, 2 of which included all 3 indices.2-4ResultsResults from 1985 vs 2000 indicate >50% improvement in swollen joints and physical function,2 maintained in 20083 and 20104 (data not shown). The search identified 32 reports with 98 comparisons of 1, 2, or 3 indices for mean or median levels or activity/severity categories (Table). Analyses of 57 means or medians indicated 10 high, 39 moderate, 8 low; for DAS28-ESR 2, 18, 2; for DAS28-CRP 1, 6, 3; for CDAI 4, 9, 3; and for RAPID3 3, 6, 0 (Table). Analyses of 41 reports of comparisons of disease activity/severity categories indicated more high/moderate in 35 vs low/remission in 6, 1 of 5 for DAS28–CRP and 5 of 15 for CDAI (Table). Remission according to DAS28, CDAI, or RAPID3 was reported in 17.1%, 10.2%, and 13.7% of patients, respectively, and low activity/severity or remission in 33.3%, 39.6%, and 29.7%, respectively (data not shown).Table 1.Means and/or Medians and categories of DAS28-ESR, DAS28-CRP, CDAI and RAPID3.Index:# of compa-risonsDAS28-ESRDAS28-CRPCDAIRAPID3Mean/Median of IndexTotal means and medians572210169High activity/severity102143Moderate activity/severity3918696Low activity/severity82330Remission00000Categories of High or Moderate Activity/Severity vs Low or RemissionTotal classified by categories41125159High or Moderate>Low or Remission35124109Low or Remission>High or Moderate60150ConclusionMost RA patients in post 2011 reports from routine care were in moderate activity according to means or medians or categories, unchanged from 2008 and 2010. Only a minority were classified as in remission or low activity/severity. Optimal RA treatment may require modification of treatment goals, further recognition of differences between patients in clinical trials and routine care, and possible new strategies for earlier identification of RA patients for treatment, in addition to new therapeutic agents.References[1]Smolen JS et al. Ann Rheumatic Dis. 2010;69(4):631-7.[2]Pincus T et al. Arthritis and Rheumatism. 2005;52(4):1009-19.[3]Pincus T et al. J Rheumatol. 2008;35(11):2136-47.[4]Pincus T et al. Arthritis Care & Research. 2010;62(2):181-9.Disclosure of InterestsNone declared

BackgroundDAS28 (disease activity score 28) is elevated in the 20-30% of patients with rheumatoid arthritis (RA) who have comorbid fibromyalgia (FM), largely on the basis of tender joint count (TJC) and patient global assessment (PATGL) [rather than swollen joint count (SJC) or erythrocyte sedimentation rate (ESR)].1 High DAS28 in the absence of clinical inflammatory activity may suggest inappropriate treatment escalation and/or changes in a treat-to-target approach. Some reports suggest removal of PATGL from criteria for remission2.ObjectivesWe analyzed the 4 DAS28-ESR component measures in reports of FM+ or FM- RA patients, to recognize the possible contribution of each to elevated DAS28 in patients with FM.MethodsWe reviewed reports from a meta-analysis of elevated DAS28 in RA patients with comorbid FM,1 and conducted a PubMed search for further reports of DAS28-ESR in FM+ or FM- RA patients in routine care. We analyzed reports that presented the 4 individual DAS-28-ESR components in FM+ vs FM- RA patients, calculated overall medians of published mean or median results, and calculated ratios of each component measure in FM+ and FM- patients.ResultsEleven reports were identified. Mean disease duration was 5-12.8 years. Median DAS28-ESR of means/medians in FM+ RA patients was 5.3, and >5.1 in 9 of 11 studies, suggesting high disease activity (moderate in 2 studies) (Table 1). By contrast, median DAS28-ESR of means/medians in FM- RA patients was 4.1, moderate (3.2–5.1) in all 11 studies (Table 1). Medians of individual DAS28-ESR components were 28.5 vs 26 for ESR, 3.25 vs 3 for SJC, 12.3 vs 5.5 for TJC, and 62.7 vs 40 for PATGL in FM+ vs FM- RA patients, respectively. Ratios of DAS28 components in FM +/FM - patients were 2.7 for TJC, 1.6 for PATGL, 1.1 for ESR, and 1.0 for SJC.Table 1.DAS28 and component measures In RA patients who have or do not have comorbid fibromyalgia and ratio of means in the two groups (FM+/FM-)MEASURESDAS28ESRSJCTJCPATGLSTUDYFM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM+/FM-FM-FM-FM-FM-FM-FM-FM-FM-FM-Ranzolin5.4, 4.01.329*,251.163.5*,2.0*1.79.5*,3*3.276*,40*1.92009Pollard6, 4.31.439,271.44.0,4.0117,62.866,401.62010Toms5.3, 3.71.439.4,28.51.44.9,3.01.614.1,2.94.960.4,32.61.82010Zammurrad 20135.3, 3.91.338.9,311.22.8,1.71.613.1,4.13.262.7,381.6Nawito5.6, 4.51.238.2,41.80.92.8,3.00.912.3,4.52.738.2,41.80.92013Ghib5.6, 4.61.223,221.15.0,6.00.815,5.52.766,44.51.52015*Joharatnam4.8, 4.41.119,171.11.0,1.0111,61.870,421.62015*Mian5.2, 4.11.320.5,19.11.11.8,2.80.615.6,7.32.157,49.51.12016Chakr5.3, 3.91.328.5,261.13.9,2.4*1.610*,3*3.356.5*,31.5*1.82017Salaffi4.5, 3.81.224,320.73.0,4.00.712,6280,701.12018*Provan5.2, 4.21.223,211.18.4,6.41.310.7,6.41.755,301.82019Median-11 Studies5.3, 4.11.328.5,261.13.2,5.3112.3,5.52.762.7,401.6* All values were reported means other than medians noted by asterisk (*).ConclusionMean DAS28-ESR indicated high vs moderate disease activity in 9 of 11 FM+ RA patient groups vs all 11 FM- RA groups, respectively. Among the 4 DAS28 component measures, TJC differed most in FM+ vs FM- RA patients followed by PATGL, while SJC and ESR were similar in both groups. The impact of TJC likely is underestimated as the DAS28 formula weights TJC twice as SJC. Elevated DAS28 in the absence of inflammation in RA FM+ patients may result as much or more from TJC as from PATGL.References[1]Duffield et al Rheumatology (Oxford). 2018;57(8):1453-1460.[2]Ferreira et al J Rheumatol. 2021.Disclosure of InterestsNone declared