Comparison of Disease Activity Score 28 Using C-reactive Protein and Disease Activity Score 28 Using Erythrocyte Sedimentation Rate in Assessing Activity and Treatment Response in Rheumatoid Arthritis: A Meta-analysis

Gwan Gyu Song; Young Ho Lee

doi:10.4078/jrd.2016.23.4.241

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Song and Lee: Comparison of Disease Activity Score 28 Using C-reactive Protein and Disease Activity Score 28 Using Erythrocyte Sedimentation Rate in Assessing Activity and Treatment Response in Rheumatoid Arthritis: A Meta-analysis

Original Article

J Rheum Dis 2016;23(4):241-249.

Published online: 31 October 2016

DOI: https://doi.org/10.4078/jrd.2016.23.4.241

Comparison of Disease Activity Score 28 Using C-reactive Protein and Disease Activity Score 28 Using Erythrocyte Sedimentation Rate in Assessing Activity and Treatment Response in Rheumatoid Arthritis: A Meta-analysis

Gwan Gyu Song, Young Ho Lee

Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea

Corresponding to: Young Ho Lee, Division of Rheumatology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Korea. E-mail: lyhcgh@korea.ac.kr

Received 1 March 2016 Revised 8 April 2016 Accepted 30 June 2016

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

We compared the Disease Activity Score 28 (DAS28) using C-reactive protein (DAS28-CRP) with DAS28 using erythrocyte sedimentation rate (DAS28-ESR) in assessing rheumatoid arthritis (RA) activity and determining European League Against Rheumatism (EULAR) response criteria.

Methods

We searched the PubMed, EMBASE, and Cochrane databases and performed a meta-analysis to examine comparisons between DAS28-CRP and DAS28-ESR by RA activity and EULAR response criteria.

Results

A total of ten studies were included in this meta-analysis. Significantly more patients were classified as having remission or low disease activity when using DAS28-CRP than when using DAS28-ESR (odds ratio [OR]=1.869, 95% confidence interval [CI]=1.180 to 2.959, p=0.008; OR=1.411, 95% CI=1.256 to 1.586, p=7.0×10⁻⁸), whereas fewer patients were classified as having high disease activity when using DAS28-CRP than when using DAS28-ESR (OR=0.534, 95% CI=0.388 to 0.734, p=1.1×10⁻⁴). More patients were classified as having good response with criteria were based on DAS28-CRP than with DAS28-ESR (OR=1.390, 95% CI=1.183 to 1.632, p=6.10×10⁻⁵).

Conclusion

Our meta-analysis demonstrates that DAS28-CRP underestimates disease activity and overestimates response by the EULAR response criteria compared to DAS28-ESR.

Keywords: DAS28-CRP, DAS28-ESR, Rheumatoid arthritis

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Figure 1.

Flow diagram of study selection process.

Figure 2.

Meta-analysis of comparison between DAS28-CRP and DAS28-ESR in assessing rheumatoid arthritis activity. DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, CI: confidence interval.

Figure 3.

Meta-analysis of comparison between DAS28-CRP and DAS28-ESR in determining EULAR response criteria. DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, EULAR: European League Against Rheumatism, CI: confidence interval.

Table 1.

Characteristics of individual studies included in the meta-analysis

First author	Country	Ethnicity	Number of patient	Age, yr (SD)	Female, %	Disease duration, yr (SD)	Correlation coefficient	DAS28-CRP (SD)	DAS28-ESR (SD)	Data		Study quality
First author	Country	Ethnicity	Number of patient	Age, yr (SD)	Female, %	Disease duration, yr (SD)	Correlation coefficient	DAS28-CRP (SD)	DAS28-ESR (SD)	Activity	Response	Study quality
Nielung, 2015 [8]	Denmark	Caucasian	75	59.7 (NA)	73	6	-	-	-	+	-	7
Sengul, 2015 [16]	Turkey	Turkish	112	55.0 (12.4)	89.3	9	0.93	-	-	-	-	8
Son, 2015 [9]	Korea	Asian	540	53.2 (12.8)	82.8	32.9 (41.2)^*	0.867	3.44 (1.15)	3.65 (1.37)	+	+	9
Siemons, 2014 [10]	Netherlands	Caucasian	682	57.69 (13.85)	62.8	0-51+	0.945	-	-	+	-	7
Tamhane, 2013 [6]	USA	African	233	52.6 (12.4)	84.6	6.6 (9.3)	-	3.90 (1.50)	4.80 (1.50)	+	-	8
Hensor, 2010 [11]	UK	Caucasian	520	57.7 (14.1)	64.2	6.0^*	-	5.80 (1.31)	6.15 (1.38)	+	+	8
Crowson, 2009 [12]	USA	Caucasian	2,417	50.7 (12.3)	81.5	NA	0.96	5.71 (1.84)	6.18 (1.98)	-	-	7
Wells, 2009 [13]	Canada	Caucasian	752	50.8 (12.7)	77.2	8.5 (7.1)	-	-	-	-	+	8
Castreón, 2008 [7]	Spain	Caucasian	220	51 (16)	76.4	5.1 (2.9)	0.91	-	-	+	-	7
Inoue, 2007 [14]	Japan	Asian	6,729	60 (NA)	82.1	9	0.946	-	-	-	-	8
Matsui, 2007 [15]	Japan	Asian	3,073	61.1 (11.4)	84.1	13.5 (10.6)	0.945	3.59 (1.25)	4.31 (1.32)	+	+	7

^* SD: standard deviation, DAS: disease activity score, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, NA: not available, +: presence, −: absence. *months, + range.

Table 2.

Meta-analysis of comparison between DAS28-CRP and DAS28-ESR according to RA activity

RA activity	Population	Number of study	r Number of patient	Test of association		Test of heterogeneity			Publication bias p-value
RA activity	Population	Number of study	r Number of patient	OR (95% CI)	p-value	Model	l p-value	I²	Publication bias p-value
Remission	Overall	6	5,268	1.869 (1.180∼2.959)	0.008	R	0.000	91.9	0.636
	Caucasian	3	1,422	1.479 (0.990∼0.210)	0.056	R	0.094	57.6
	Asian	2	3,613	1.751 (0.695∼4.408)	0.235	R	0.000	97.0
	African	1	233	4.507 (2.371∼8.564)	4.3×10⁻⁵	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA
Low	Overall	7	5,343	1.411 (1.256∼1.586)	7.0×10⁻⁸	F	0.213	28.2	0.207
	Caucasian	4	1,497	1.028 (0.789∼1.339)	0.839	F	0.191	0
	Asian	2	3,613	1.520 (1.330∼1.736)	＜1.0×10⁻⁸	F	0.834	0
	African	1	233	1.583 (0.892∼2.807)	0.116	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA
Moderate	Overall	7	5,343	0.995 (0.869∼1.459)	0.947	R	0.078	47.1	0.199
	Caucasian	4	1,497	1.104 (0.836∼1.459)	0.484	R	0.057	60.1
	Asian	2	3,613	0.916 (0.835∼1.005)	0.063	F	0.398	0
	African	1	233	0.885 (0.613∼1.277)	0.513	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA
High	Overall	7	5,343	0.534 (0.388∼0.734)	1.1×10⁻⁴	R	0.000	85.7	0.210
	Caucasian	4	1,497	0.712 (0.598∼0.849)	1.5×10⁻⁴	F	0.618	0
	Asian	2	3,613	0.396 (0.283∼0.554)	6.0×10⁻⁸	R	0.092	64.8
	African	1	233	0.443 (0.296∼0.663)	7.6×10⁻⁵	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA

DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, RA: rheumatoid arthritis, OR: odds ratio, CI: confidence interval, F: fixed effects model, R: random effects model, NA: not available.

Table 3.

Meta-analysis of comparison between DAS28-CRP and DAS28-ESR according to EULAR response criteria

EULAR response	Population	Number of study	Number of patient	Test of association		Test of heterogeneity			Publication bias p-value
EULAR response	Population	Number of study	Number of patient	OR (95% CI)	p-value	Model	p-value	I²	Publication bias p-value
Good	Overall	4	2,596	1.390 (1.183∼1.632)	6.1×10⁻⁵	F	0.590	0	0.011
	Caucasian	2	1,036	1.420 (1.152∼1.752)	0.001	F	0.763	0
	Asian	2	1,560	1.347 (1.048∼1.732)	0.020	F	0.189	42.0
	African	0	NA	NA	NA	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA
Moderate	Overall	4	2,596	0.913 (0.807∼1.035)	0.154	F	0.517	0	0.284
	Caucasian	2	1,036	0.853 (0.716∼1.016)	0.075	F	0.962	0
	Asian	2	1,560	0.980 (0.821∼1.170)	0.823	F	0.297	7.94
	African	0	NA	NA	NA	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA
No	Overall	4	2,596	0.900 (0.796∼1.017)	0.092	F	0.418	0	0.183
response	Caucasian	2	1,036	0.897 (0.739∼1.090)	0.275	F	0.873	0
	Asian	2	1,560	1.061 (0.623∼1.807)	0.828	F	0.094	64.4
	African	0	NA	NA	NA	NA	NA	NA
	Turkish	0	NA	NA	NA	NA	NA	NA

DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, EULAR: European League Against Rheumatism, OR: odds ratio, CI: confidence interval, F: fixed effects model, NA: not available.

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