Evaluation of disease activity in rheumatoid arthritis by Routine Assessment of Patient Index Data 3 (RAPID3) and its correlation to Disease Activity Score 28 (DAS28) and Clinical Disease Activity Index (CDAI): an Indian experience

Serial objective assessment of disease activity in rheumatoid arthritis (RA) is imperative to achieve remission. Routine Assessment of Patient Index Data 3 (RAPID3), an index without formal joint counts, appears attractive for evaluation of disease activity in RA patients in a busy clinical setting. This study aims to evaluate correlation and agreement of RAPID3 with Disease Activity Score 28 (DAS28) and Clinical Disease Activity Index (CDAI) in RA patients. All patients completed a Multidimensional Health Assessment Questionnaire (MDHAQ) at each visit. A physician/assessor 28-joint count and erythrocyte sedimentation rate were completed in 200 literate patients with RA to score DAS28, CDAI, and RAPID3. RAPID3 includes the three MDHAQ patient self-report RA core dataset measures for physical function, pain, and patient global estimate. Proposed RAPID3 (range, 0?C30) severity categories of high (>12), moderate (6.1?C12.0), low (3.1?C6.0), and near remission (??3) were compared to DAS28 (0?C10) activity categories of high (> 5.1), moderate (3.21?C5.1), low (2.61?C3.2), and remission (?? 2.6), and CDAI (0?C76) categories of >22, 10.1?C22.0, 2.9?C10.0, and ??2.8. Statistical significance was analyzed using Spearman correlations, cross-tabulations, and kappa statistics. Comparison of RAPID3 with DAS28 and CDAI indicated Spearman rank-order correlation coefficients for DAS28 with RAPID3 of 0.910, and for CDAI with RAPID3 of 0.907, all highly significant (P?<?0.001). There was substantial agreement between RAPID3 and DAS28 (kappa value?=?0.634, P?<?0.001) and also between RAPID3 and CDAI (kappa value?=?0.690, P?<?0.001). Overall, 89?C94?% of patients who met DAS28 or CDAI moderate/high activity criteria met similar RAPID severity criteria and 84?C88?% who met DAS28 or CDAI remission/low activity criteria also met similar RAPID criteria. RAPID3 scores provide similar quantitative information to DAS28 and CDAI, and hence, is an informative index for evaluation of disease activity in RA in busy clinical settings.     

Evaluation of the preliminary definitions of minimal disease activity and remission in an early seropositive rheumatoid arthritis cohort

OBJECTIVE: To evaluate published proposed definitions of minimal disease activity (MDA) and remission in patients with early rheumatoid arthritis (RA). METHODS: The cohort comprised disease-modifying antirheumatic drug (DMARD)-naive patients with early seropositive active RA (n = 200) treated with traditional DMARDs in the prebiologic era. MDA definitions included Disease Activity Score in 28 joints (DAS28) 相似文献   

Validation of RAPID3 using a Japanese version of Multidimensional Health Assessment Questionnaire with Japanese rheumatoid arthritis patients: Characteristics of RAPID3 compared to DAS28 and CDAI

Abstract

Objectives. To validate Routine Assessment of Patient Index Data 3 (RAPID3) using a Japanese version of Multidimensional Health Assessment Questionnaire (MDHAQ) with Japanese rheumatoid arthritis (RA) patients and to describe the characteristics of RAPID3 by comparison with Disease Activity Score 28 (DAS28) and Clinical Disease Activity Index (CDAI).

Methods. The original MDHAQ was translated into Japanese with minor cultural modifications and was translated back in English. Test–retest reliability was evaluated in 50 Japanese RA patients and further validation was performed in 350 Japanese RA patients recruited by seven rheumatologists. RAPID3, CDAI, and DAS28 were assessed on two consecutive visits.

Results. The test–retest reliability and the internal reliability of RAPID3 were excellent. Spearman's correlation coefficients between RAPID3 score versus CDAI score and DAS28 score were 0.761and 0.555. However, the agreement measured by kappa (weighted) for RAPID3 category versus CDAI category and for RAPID3 category versus DA28 category were 0.225 (0.382) and 0.187 (0.336). The sensitivity and specificity of “RAPID3 ≤ 3 and swollen joint ≤ 1” for predicting Boolean remission were 90.0% and 93.4%, respectively.

Conclusions. RAPID3 obtained by Japanese MDHAQ was validated with Japanese RA patients and the remission criteria were found to have excellent clinical utility in usual care.     

RAPID3 (Routine Assessment of Patient Index Data 3) severity categories and response criteria: Similar results to DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index) in the RAPID 1 (Rheumatoid Arthritis Prevention of Structural Damage) clinical trial of certolizumab pegol

Objective

To compare categories for activity/severity according to the Disease Activity Score 28‐joint count (DAS28), the Clinical Disease Activity Index (CDAI), and the Routine Assessment of Patient Index Data 3 (RAPID3), an index without formal joint counts calculated in 5 versus >100 seconds, as well as the European League Against Rheumatism (EULAR)– DAS28 and the RAPID3 response criteria, in the Rheumatoid Arthritis Prevention of Structural Damage (RAPID 1) clinical trial of certolizumab pegol (CZP).

Methods

Post hoc analyses were performed using correlations, cross‐tabulations, and kappa statistics. Patients (treated with CZP plus methotrexate [MTX] or placebo plus MTX) were classified at baseline and at 52 weeks as high, moderate, low activity/severity or remission, according to the DAS28 (>5.1, >3.2 to ≤5.1, 2.6 to ≤3.2, <2.6 [total range 0–10]), the CDAI (>22, >10 to ≤22, >2.8 to ≤10, ≤2.8 [total range 0–76]), and RAPID3 (>12, >6 to ≤12, >3 to ≤6, ≤3 [total range 0–30]), as well as for good, moderate, and poor EULAR‐DAS28 and proposed RAPID3 response criteria.

Results

All measures were correlated significantly: RAPID3 with DAS28 and CDAI (rho > 0.7), higher than erythrocyte sedimentation rate with C‐reactive protein level (rho = 0.47). At 52 weeks, DAS28, CDAI, and RAPID3 low activity/remission was seen in 30%, 44%, and 42% of CZP‐treated patients versus 3%, 7%, and 10% of control patients. Good, moderate, and poor EULAR‐DAS28 responses were seen in 30%, 51%, and 19% of CZP‐treated patients versus 3%, 28%, and 70% of control patients, and for RAPID3 in 39%, 30%, and 32% of CZP‐treated patients versus 8%, 16%, and 76% of control patients. Kappa and weighted kappa values ranged from 0.36–0.53, indicating fair to moderate agreement.

Conclusion

RAPID3, DAS28, and CDAI give similar results to distinguish CZP patients from controls in the RAPID 1 clinical trial. DAS28 is specific for clinical trials; RAPID3 appears pragmatically useful for usual care.     

Assessing remission in clinical practice

OBJECTIVE: Remission constitutes the best achievable state in patients with rheumatoid arthritis. We aimed at evaluating sustained remission in a large cohort of patients followed prospectively in clinical practice and to evaluate available instruments to define remission for their stringency in defining this state. PATIENTS AND METHODS: We analysed remission and sustained remission in 621 patients who had two consecutive and complete clinical observations; the average period between the two visits was 92 days (median; quartiles: 82; 105). Remission was evaluated according to modified ACR (mACR), 28 Joint Disease Activity Score (DAS28), Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) criteria. Sustained remission was defined as remission at both consecutive visits. Patients were treated with traditional disease- modifying antirheumatic drugs, mainly methotrexate, and partly with biological agents (approximately 11%). RESULTS: Remissions at any one of the two visits were seen in 33.5% of patients by SDAI or CDAI, 42.7% by DAS28, and 38.6% by mACR criteria (P < 0.01). Sustained remission was observed in much lower proportions of patients (between 16.7 and 19.6%, dependent on the instrument). Agreement between classifications of remission by kappa-statistics was very good for SDAI vs CDAI, good for DAS28 vs SDAI or CDAI, and only moderate for mACR vs the three other scores. Residual swollen joints were observed in 15% of patients in DAS28 remission (range 1-9), 6% of patients in mACR remission (range 1-8), but only approximately 5% of patients in CDAI or SDAI remission (range 1-2) (P < 0.01). CONCLUSION: Sustained remission can be observed in 17-20% of patients in clinical practice. CDAI and SDAI remission criteria are more stringent than DAS28 and mACR criteria, since they allow for lesser residual disease activity. Consequently, smaller proportions of patients are classified as in remission by SDAI and CDAI than by DAS28 and mACR criteria. Sustained remission is an achievable goal in clinical practice even with the most stringent of the definitions studied.     

RAPID3 (Routine Assessment of Patient Index Data) on an MDHAQ (Multidimensional Health Assessment Questionnaire): Agreement with DAS28 (Disease Activity Score) and CDAI (Clinical Disease Activity Index) activity categories,scored in five versus more than ninety seconds

Objective

To compare the Routine Assessment of Patient Index Data 3 (RAPID3) on a Multidimensional Health Assessment Questionnaire (MDHAQ) with the Disease Activity Score (DAS28), Clinical Disease Activity Index (CDAI), and individual core data set measures for correlations, agreement of activity levels, and time to score.

Methods

Four rheumatologists each assessed 50 patients with rheumatoid arthritis in “real‐time” clinical care. Patients completed an MDHAQ. The rheumatologist then calculated RAPID3 (physical function, pain, patient global estimate), performed a 28‐joint count, assigned a physician global estimate, and scored a CDAI, each timed by an observer. Erythrocyte sedimentation rate (ESR) was tested on the same date, and the DAS28‐ESR was computed later, again timed by an observer. Spearman's rank‐order correlations and comparisons of patients classified as high activity, moderate activity, low activity, and remission according to the DAS28, CDAI, and RAPID3 were computed and compared with kappa statistics. A second study of 25 “paper patients” was also performed to compare time to score the DAS28, CDAI, and RAPID3 on a 0–10 versus 0–30 scale. Mean and median times to score each index were computed.

Results

The 3 indices were correlated significantly, including agreement for >80% of patients for high/moderate activity. The mean time to perform a 28‐joint count was 94 seconds, and the mean times to score the DAS28, CDAI, RAPID3 on a 0–10 scale, and RAPID3 on a 0–30 scale were 114, 106, 9.6, and 4.6 seconds, respectively.

Conclusion

RAPID3 scores provide similar quantitative information to DAS28 and CDAI, while calculated on a 0–30 scale in about 5% of the time.     

Interleukin‐6 receptor inhibition with tocilizumab and attainment of disease remission in rheumatoid arthritis: The role of acute‐phase reactants

Objective

To determine the effects of tocilizumab on rheumatoid arthritis (RA) disease activity and remission assessment, using measures that do or do not comprise acute‐phase reactants.

Methods

Simplified Disease Activity Index (SDAI) scores, Clinical Disease Activity Index (CDAI) scores, and the Disease Activity Score in 28 joints (DAS28) were calculated using data from tocilizumab trials in patients with RA in whom disease had remained active despite treatment with disease‐modifying antirheumatic drugs. The CDAI does not contain an acute‐phase reactant component. Disease activity states, including remission, were defined using established cut points; for the DAS28, an alternative cut point of <2.4 was also used.

Results

Changes in the DAS28, the SDAI score, and the CDAI score among patients receiving tocilizumab were significantly higher than those among patients receiving placebo, and the magnitude of these changes was similar for the SDAI and the CDAI. Among patients who achieved 50% improvement in disease activity according to the American College of Rheumatology criteria, only ∼20% required a reduction in acute‐phase reactant values in order to fulfill the criteria. However, DAS28 remission rates were higher (even when using the lower cut point) than the SDAI and CDAI remission rates. Only a minority of tocilizumab‐treated patients with DAS28 remission also had disease remission according to the SDAI (26%) or CDAI (∼21%). With infliximab treatment, SDAI and CDAI remission rates were of the same magnitude as those observed with tocilizumab treatment, and DAS28 remission rates were lower. Tocilizumab‐treated patients with DAS28 remission but without CDAI remission had significantly higher swollen joint counts but lower erythrocyte sedimentation rates (ESRs) compared with patients with SDAI or CDAI remission.

Conclusion

Disease activity in RA is reduced by tocilizumab treatment, irrespective of the type of composite measure used to evaluate disease activity. Remission rates were much higher using the DAS28 compared with the SDAI and CDAI, due to the high weight of the ESR in the DAS28 and the effect of tocilizumab on the ESR. Using the stringent SDAI and CDAI criteria, however, remission rates in patients treated with tocilizumab were in the same range as those seen in patients treated with tumor necrosis factor inhibitors.

     

The problem of rheumatoid arthritis disease activity and remission in clinical practice

OBJECTIVE: To investigate the results and feasibility of available scales to measure minimal disease activity (MDA) and remission in rheumatoid arthritis (RA) in the clinic. METHODS: We studied 849 consecutive patients with RA seen in a community rheumatology practice for routine RA care by 4 rheumatologists, beginning in March 2007 and ending in August 2007. Patients and physicians completed a simple form at each visit. We calculated the Disease Activity Score 28 (DAS28), Clinical Disease Activity Index (CDAI), physician assessment of global activity, and the Patient Activity Scale (PAS-II). From these we calculated remission and MDA prevalence in this community practice. RESULTS: The DAS28 could not be determined in more than 50% of patients because of referring physician and insurance company restrictions. Remission prevalences differed by assessment method: DAS28 28.5%, CDAI 6.5%-8.1%, physician global 12.5%, PAS 13.7%. MDA was 26.9% using the American College of Rheumatology core set variables, 34.7% using the DAS28, and 26.8% using the PAS-II. The kappa statistic was only fair (0.2 to 0.4) for most comparisons between assessment methods. No significant differences were noted for remission and MDA according to biologic therapy. CONCLUSION: The CDAI and/or physician global and PAS-II are simple acceptable ways to measure RA activity in the clinic, but results differ strikingly according to method. Further standardization appears to be required for full implementation of the CDAI. Caution is urged before using these methods for regulatory purposes.     

不同缓解标准下类风湿关节炎临床缓解与持续临床缓解率:一项单中心观察性研究

目的分析本中心RA队列中不同缓解标准下的临床缓解率与持续临床缓解率。方法纳入2011年1月1日至2016年12月31日所有就诊于北京大学第一医院风湿免疫科门诊的RA患者,收集首次就诊至2018年6月或末次随访的所有门诊病历资料,分别以DAS28-ESR、简化疾病活动度指数(SDAI)、临床疾病活动度指数(CDAI)、Boolean标准评价疾病活动度值和/或临床缓解状态,持续缓解定义为维持临床缓解时间>6个月。采用Kaplan-Meier生存分析计算RA患者的累积缓解率与中位达临床缓解时间。采用Cox多因素回归分析持续缓解的相关因素。结果本研究共连续纳入648例患者,在中位24个月的随访过程中,分别有510例(78.7%)、459例(70.8%)、443例(68.4%)、445例(68.7%)患者至少1次达到过临床缓解。其中,第3、6、12个月的累积临床缓解率分别为10.6%~24.4%、25.3%~43.5%、51.8%~65.2%,患者达首次临床缓解的中位时间为7.2~11.4个月。在随访过程中,分别有338例(52.2%)、302例(46.6%)、292例(45.1%)、283例(43.7%)患者至少1次实现DAS28-ESR、SDAI、CDAI和Boolean标准定义下的持续缓解。在这些达持续缓解的患者中,维持缓解状态的中位时间分别为16.0个月(DAS28-ESR),15.4个月(CDAI),14.9个月(SDAI)和15.0个月(Boolean标准)。在达到持续缓解的患者中,DMARDs单药和联合用药的比例分别为18.7%(73/390)、81.3%(317/390),此外,22.3%(87/390)的患者接受小剂量激素治疗,超过半数患者(51/87)在持续临床缓解期间减停激素。结论在临床工作中,临床缓解是切实、可行的治疗目标,经过规范的临床治疗,超过半数的患者可在治疗1年内实现临床缓解。而在实现临床缓解的患者中,大部分可实现持续临床缓解,维持缓解状态的中位时间为15个月左右。     

A proposed continuous quality improvement approach to assessment and management of patients with rheumatoid arthritis without formal joint counts, based on quantitative routine assessment of patient index data (RAPID) scores on a multidimensional health assessment questionnaire (MDHAQ)

A continuous quality improvement approach is proposed for the assessment and management of patients with rheumatoid arthritis (RA) based on scores on a one-page patient self-report multidimensional health assessment questionnaire (MDHAQ), without formal joint counts. The approach includes five simple steps before the patient is seen by the physician: (1) an MDHAQ is completed by every patient at every visit; (2) scores are calculated for patient function, pain, and global estimate, with options for a self-report joint count and other scales; (3) scores are entered on flow sheets with data from prior visits, which might also include laboratory and medication information; (4) scores are compiled into an index termed Routine Assessment of Patient Index Data (RAPID), analogous to a Disease Activity Score (DAS); (5) RAPID scores are classified to guide treatment decisions. RAPID 3 includes the three patient-reported outcome (PRO) measures in the RA Core Data Set - physical function, pain, and global estimate. RAPID 4 adds a self-report joint count, and RAPID 5, a physician global estimate. RAPID 3 can be calculated in about 10 seconds, RAPID 4 in about 19 seconds, and RAPID 5 in about 20 seconds. RAPID 3, RAPID 4, and RAPID 5 give similar results to distinguish active from control treatments in RA clinical trials, at levels similar to American College of Rheumatology or DAS improvement criteria, and are all correlated significantly with DAS28 (rho=0.62-0.64, P<0.001). A proposed classification of RAPID scores, analogous to four DAS28 categories, includes: 'near remission' (0-1), 'low severity' (1.01-2), 'moderate severity' (2.01-4), and 'high severity' (>4). RAPID scoring is feasible in standard clinical care to support continuous quality improvement.     

Time to score quantitative rheumatoid arthritis measures: 28-Joint Count, Disease Activity Score, Health Assessment Questionnaire (HAQ), Multidimensional HAQ (MDHAQ), and Routine Assessment of Patient Index Data (RAPID) scores

OBJECTIVE: To analyze the time required to score different measures used to assess patients with rheumatoid arthritis (RA), as a guide to feasibility in standard care. The measures studied were a 28-Joint Count, Disease Activity Score (DAS), Health Assessment Questionnaire (HAQ), Multidimensional HAQ (MDHAQ), and various Routine Assessment of Patient Index Data (RAPID) scores derived from the MDHAQ. METHODS: Three rheumatologists at 3 sites performed and timed 28-joint counts in 20 different patients at each site. Each rheumatologist scored and timed identical data in 5 groups of 10 from the same 50 patients seen in standard clinical care, including 50 DAS28 indices using the DAS Website, 50 identical HAQ, and 50 identical MDHAQ from the same patients. The MDHAQ includes 10 activities self-assessed for physical function, 21 circle visual analog scales (VAS) (rather than 10 cm lines), and scoring templates on the questionnaire for physical function, patient self-report joint count and RAPID composite scores. RAPID3 includes the 3 Core Data Set measures, RAPID4 adds the self-report joint count to RAPID3, and RAPID5 adds a physician global estimate to RAPID4. RESULTS: The median number of seconds to complete a 28-joint count was 90, compared to 41.9 s for a HAQ, 9.6 s for an MDHAQ RAPID3, and 19.4 s for RAPID5. CONCLUSION: MDHAQ RAPID3 scores can be calculated in considerably less time than other RA measures, using scoring templates on the MDHAQ, to provide informative, feasible, quantitative measures for standard rheumatology clinical care.     

Performance of Routine Assessment of Patient Index Data 3 (RAPID3) for assessment of rheumatoid arthritis in clinical practice: differential agreement of RAPID3 according to disease activity categories

To evaluate the performance of Routine Assessment of Patient Index Data 3 (RAPID3) with the disease activity score 28 (DAS28) and the clinical/simplified disease activity index (CDAI/SDAI) in a Korean population with rheumatoid arthritis (RA). Four hundred patients with RA were consecutively enrolled. All patients completed disease activity indices such as RAPID3, DAS28, SDAI, and CDAI. The kappa and/or weighted coefficients were used to assess agreement between RAPID3 and other disease activity indices. ANOVA, Mantel–Haenszel chi-square test, and Spearman’s partial correlation analysis were used for analyses. RAPID3 scores were significantly correlated with DAS28 (r = 0.62), SDAI (r = 0.74), and CDAI (r = 0.75; p < 0.0001 for all indices) and other activity measures including swollen/tender joint counts, erythrocyte sediment rate, and C-reactive protein. The weighted kappa coefficients of RAPID3 with DAS28, SDAI, and CDAI among the four disease activity categories were 0.33, 0.34, and 0.33, respectively. Kappa coefficients for RAPID3 in two disease activity categories increased more than four categories (κ = 0.40–0.42) indicating fair agreement. More than 86 % of patients with high-to-moderate disease activity in DAS28, CDAI, and SDAI had high-to-moderate disease activity using RAPID3 criteria. However, approximately 50 % of patients with remission-to-low disease activity in DAS28, CDAI, and SDAI showed remission-to-low disease activity in RAPID3. This study confirms RAPID3 as an informative disease activity index with equivalent values in DAS28, CDAI, and SDAI. RAPID3 reveals differential agreement in patients with lower disease activity.     

Reexamination of the assessment criteria for rheumatoid arthritis disease activity based on comparison of the Disease Activity Score 28 with other simpler assessment methods

Objective

To explore simpler and possibly more appropriate tools than the conventional Disease Activity Score 28 (DAS28) for assessing rheumatoid arthritis (RA) and to derive more reliable DAS28-based criteria.

Methods

The capabilities of assessing disease activities in 250 RA patients were compared between DAS28 and other methods, including the Simplified DA Index (SDAI), Clinical DA Index (CDAI), and Routine Assessment of Patient Index Data-3 (RAPID-3).

Results

SDAI and CDAI showed a good correlation and consistency with DAS28, whereas RAPID-3 yielded inferior results. In terms of remission criteria, DAS28 was less stringent than SDAI or CDAI; when RA remission was reexamined based on more stringent SDAI or CDAI criteria, cut-off values for DAS28-C-reactive protein of <1.72 were considered to be appropriate. The conventional DAS28 was considered to be appropriate for assessing low, middle and high disease activities because it provides criteria similar to or more stringent than those of other methods, while SDAI and CDAI were considered to be simpler and more appropriate criteria for assessing remission.

Conclusion

For assessing remission, DAS28-CRP provides the most appropriate criterion of the methods compared when the currently used cut-off value of 2.3 is lowered to a new value of 1.72.     

Value of Disease Activity Score 28 (DAS28) and DAS28-3 compared to American College of Rheumatology-defined remission in rheumatoid arthritis

OBJECTIVE: To assess the criteria for remission based on Disease Activity Score 28 (DAS28) and DAS28-3 (excluding patients' evaluation of disease activity) compared to American College of Rheumatology (ACR) preliminary criteria in established rheumatoid arthritis (RA), and to examine the value of each ACR criterion individually. METHODS: The EMECAR study was designed to assess the burden of comorbidity and inflammatory activity for RA in Spain. A random sample of 788 patients with RA from 34 Spanish centers was selected. Remission was defined by preliminary ACR criteria applied specifically and the clinical activity assessed by the DAS28 and the DAS28-3. A receiver operating characteristics curve analysis was performed to identify cutoff values with the highest usefulness in defining remission on both DAS indices. RESULTS: Thirty-two patients (4.1%) were in ACR-defined remission, 62 (7.9%) if fatigue was excluded from the criteria. The frequency of any single criterion that patients in remission fulfilled: no fatigue and joint pain by anamnesis in 31 patients (96.9%); morning stiffness < 15 min in 26 (81.3%); no swelling in joints in 21 (65.6%); normal erythrocyte sedimentation rate (ESR) in 29 (90.6%); and no joint tenderness in 21 (65.6%) patients. The positive predictive value for remission of each criterion: normal ESR 6.5%; morning stiffness < 15 min 8.4%; no fatigue 8.7%; no joint tenderness 13%; no swelling in joints 15.8%; and no joint pain by anamnesis 27.7%. The DAS28 cutoff values with higher discriminatory power for remission were 3.14 (sensitivity 87%; specificity 67%) when all the ACR criteria were used, and 2.81 (sensitivity 84%; specificity 81%) when fatigue was omitted. The equivalent cutoffs for the DAS28-3 were 3.52 (sensitivity 84%; specificity 66%) and 2.95 (sensitivity 82%; specificity 83%), respectively. CONCLUSION: DAS28 and DAS28-3 are good tools to define remission in established RA. No joint pain by anamnesis is the criterion with the highest value in defining remission, while normal ESR, an absence of morning stiffness, and fatigue are the least effective.     

Comparison of different definitions to classify remission and sustained remission: 1 year TEMPO results

OBJECTIVE: To assess methods to calculate achieving and sustaining remission in a double blind randomised trial in patients with RA who received etanercept, methotrexate, or an etanercept/methotrexate combination. METHODS: Remission was defined as DAS <1.6, DAS28 <2.6, and ACR70 response. Sustaining remission was analysed in three ways: (a) analysis of sustained DAS remission, DAS28 remission, or ACR70 response continuously for 6 months; (b) analysis of sustained remission appraised through a continuity rewarded scoring system, which is the weighted sum of all intervals in the study in which patients are in DAS or DAS28 remission; or (c) longitudinal modelling of remission odds using generalised estimating equations. RESULTS: Significantly more patients treated with the etanercept/methotrexate combination reached DAS remission (37%) than those treated with either methotrexate (14%) or etanercept (18%) alone (p<0.01). Results for DAS28 and for the ACR70 response were similar. Agreement between DAS remission and DAS28 remission was good, but agreement between either of these and the ACR70 response was less. Patients in DAS or DAS28 remission had a lower level of disease activity (fewer active joints, lower ESR) than those achieving ACR70 response; the converse was seen using pain VAS. The three methods were comparable for sustainability of remission and showed significant advantage for combination therapy, which increased the number and durability of remission periods. CONCLUSIONS: DAS and DAS28 remission results were similar for assessing achieving and sustaining remission in RA, frequently differing from patients classified as ACR70 responders. The three methods of examining duration of remission produced comparable results.     

Sustained remission and reduced radiographic progression with combination disease modifying antirheumatic drugs in early rheumatoid arthritis

OBJECTIVE: To study sustainability of remission and good treatment response, and the association of both with radiographic progression, in early rheumatoid arthritis (RA) in the Finnish Rheumatoid Arthritis Combination Therapy trial (FIN-RACo). METHODS: Patients were randomized to receive either a combination of disease modifying antirheumatic drugs (DMARD; COMBI, n = 97) or a single DMARD (SINGLE, n = 98). Remission was defined according to modified American College of Rheumatology (ACR) remission criteria and Disease Activity Score 28 joint count (DAS28) < or = 2.6, and sustained remission as presence of remission at 6, 12, and 24 months. Good treatment response was defined as DAS28 (3/4) 3.2 and decrease of DAS28 >1.2. RESULTS: In 169 patients with complete data, 33 (42%) COMBI and 18 (20%) SINGLE patients achieved modified ACR remission at 2 years, which was sustained in 11 (14%) COMBI and 3 (3%) SINGLE patients. Fifty-four (68%) COMBI and 37 (41%) SINGLE patients were in DAS28 remission at 2 years, which was sustained in 40 (51%) COMBI and 14 (16%) SINGLE patients. Good treatment response was sustained in 67% of COMBI and 27% of SINGLE patients. Over 2 years, the Larsen score increased by a median of 1 (95% CI 0-2) in patients in sustained DAS28 remission compared to 4 (95% CI 2-16) in patients who were in DAS28 remission at 6 months but lost it later; and by 6 (95% CI 2-10) in patients who were not in remission at 6 months. CONCLUSION: A remarkable proportion of patients with early RA treated with combinations of DMARD were in remission at 2 years, and remission was more often sustained compared to patients treated with a single DMARD. Sustained remission protects against radiographic joint damage.     

DAS 28 for defining remission in rheumatoid arthritis in Indian patients

ObjectiveTo establish DAS 28 and DAS 28-3 scores that best define remission in Indian patients with rheumatoid arthritis (RA).Patients and MethodsAll patients diagnosed with RA visiting AIIMS, New Delhi over a period of 3 months were recruited. Clinical assessment included 28 joint counts for swelling and tenderness, duration of early morning stiffness, patient global assessment of disease activity, fatigue, joint pains and ESR. DAS 28 and DAS 28-3 scores were calculated and receiver operating characteristics curve analysis was performed to define cutoff values utilizing ‘ACR 5/6’ and ‘ACR 4/5’ remission criteria.ResultsSubjects included 207 patients (M: 44; F: 163) with mean age of 47.4 ± 12.6 years, median disease duration of 8 [4.12–14] years.‘ACR 5/6’ and ‘ACR 4/5’ criteria for remission were satisfied by 34 (16.42%) and 44 patients (21.25%) patients, respectively. DAS 28 score of 2.94 (sensitivity 84.4%, specificity 85.3%) and DAS 28-3 score of 3.02 (sensitivity 82.1%, specificity 82.4) best defined the ‘ACR 5/6’ remission. Corresponding values using ‘ACR 4/5’ remission were 3.04 (sensitivity 85.9%, specificity 84.1%) for DAS 28 and 3.05 (sensitivity 82.2%, specificity 81.8%) for DAS 28-3.ConclusionsA cutoff value < 3 for both DAS 28 and DAS 28-3 defines remission in RA in Indian patients.     

Comparison between different disease activity scores in rheumatoid arthritis: an Egyptian multicenter study

The aim of our work was to assess the performance of different Disease Activity Score (DAS) other than DAS-ESR in daily clinical practice in our Egyptian outpatient clinics and also to evaluate the accuracy of European League Against Rheumatism Classification (EULAR) proposed cutoffs for these scores to stratify Egyptian patients into different categories of disease activity. This study is a cross-sectional Egyptian multicenter study. It included 130 rheumatoid arthritis (RA) patients who visited our Rheumatology and Rehabilitation outpatient and inpatient clinics; 80 patients from Cairo University Hospitals and 50 patients from Zagazig University Hospitals. The patients fulfilled the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism Classification criteria for rheumatoid arthritis. Disease Activity Score 28-ESR (DAS28-ESR), DAS28-CRP, Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) were calculated. A significant positive correlation was found between all three scores and morning stiffness, ESR, Modified Health Assessment Questionnaire (MHAQ), and DAS-ESR. Also, there was a significant negative correlation between DAS-CRP and hemoglobin and a significant positive correlation with CRP. Also, there was a highly significant moderate agreement between DAS-ESR and DAS-CRP using Fleischmann et al. thresholds and also between DAS-ESR and SDAI. While a highly significant fair agreement was found between DAS-ESR and DAS-CRP using DAS-ESR thresholds and between DAS-ESR and CDAI. We conclude that DAS-CRP, SDAI, and CDAI are very useful in representing disease activity in RA patients in our outpatient clinics being well correlated with many markers of disease activity. We recommend huge multicenter studies in Egypt and in different populations to define new cutoff values to optimize their use in clinical setting.     

Clinical remission and/or minimal disease activity in patients receiving adalimumab treatment in a multinational, open-label, twelve-week study

OBJECTIVE: To evaluate the effect of adalimumab treatment on clinical remission and/or minimal disease activity (MDA) in 6,610 patients with active rheumatoid arthritis (RA) who were enrolled in the Research in Active RA trial, a multinational, open-label, 12-week study with an optional extension period. METHODS: Clinical remission was defined as a Disease Activity Score in 28 joints (DAS28)<2.6, Simplified Disease Activity Index (SDAI) score相似文献