Revising DAS28 scores for remission in rheumatoid arthritis

Abstract

Current initiatives to treat rheumatoid arthritis (RA) to target remission have resulted in the widespread use of composite outcome measures to quantify disease activity. Simplified Disease Activity Index (SDAI) ≤3.3 is the gold standard of remission. Previous work has suggested that the remission threshold of DAS28-ESR or DAS28-CRP ≤2.6 is known to be not strict enough and should be revised. There is no previous study that looks at the equivalent DAS28-CRP value that best reflects SDAI remission in a real-life cohort. Consecutive cases fulfilling ACR/EULAR classification criteria for RA from one centre were included if they had an optimum number of visits with recording of all raw data to calculate DAS28-ESR, DAS28-CRP and SDAI. Data from seven visits each of 76 patients, providing 532 data points was examined. Spearman's correlation between DAS28-ESR, DAS28-CRP and SDAI was 0.91-0.97 (p < 0.001). A Bland-Altman plot demonstrated a mean difference of 0.37 units between DAS28-ESR and DAS28-CRP (p < 0.001). ROC and kappa analysis provided values of 2.58 and 2.55 for DAS28-ESR4V and 2.09 and 2.05 for DAS28-CRP4V for SDAI value of 3.3, respectively. The two versions of DAS28 using ESR and CRP and SDAI correlate but are not equivalent or interchangeable for an individual patient. The DAS28-CRP overestimates remission and should be revised downwards to a proposed value of 2.1.

The MRI Features in Patients with Rheumatoid Arthritis Treated with Tocilizumab, in Clinical Remission or Low Disease Activity State

“…Matsui et al suggested that DAS28-CRP underestimated disease activity. Inoue et al found DAS28-CRP 2.3 matched DAS28-ESR remission in Japanese patients [10].The present study suggests that composite scores overestimate remission and patients retain subclinical inflammation found on MRI. Our results join the various studies that have proven the dissociation between clinical remission according different composite scores and remission in imaging either by ultrasound (Ramirez J et al [11]) or MRI (Gandjbakhch F et al [12]) or both (Foltz V et al [13]).…”

“…There are several composite measures which correlate well, higher values having poor functional and radiologic outcomes, but there remains disagreement in classifying disease activity states. Disease activity score assessing 28-joint (DAS28) versions using erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have good correlation but not equivalence but it's overestimated remission compared to all other criteria [10]. The American college of rheumatology (ACR) and the European league against rheumatism (EULAR) have defined remission as a simplified disease activity index (SDAI) value of ≤ 3.3 (index-based definition).…”

Methodological issues in the design of a rheumatoid arthritis activity score and its cut-offs

“…Remission can currently be confirmed when the DAS28 score is lower than 2.4, or confirmed independently using the 2010 American College of Rheumatology (ACR)/EULAR criteria 7,17,20. Although both rules share common items, discrepancies exist and the need for guidelines has been pointed out 21. Shaver et al already reported some inconsistencies using published cut-offs for remission of DAS28 and CDAI and therefore recommend cautious use of these with patients 22…”

„Treat to target“ und personalisierte Medizin („precision medicine“)

“…Erste Daten zeigen, dass bei einem frühzeitigen Therapiebeginn bei einigen Patienten sogar arzneimittelfreie Intervalle erreichbar sind [18]. [24,25]. Zur Therapieanpassung stehen v. a. für die Behandlung von RA-Patienten zahlreiche altbewährte, aber auch moderne Medikamente wie Biologika und aktuell BiosiAbb.…”