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Abstract
Objective
Assessing the disease activity is a key part of clinical decision-making in rheumatology. In particular, a high disease activity, which is represented by a disease activity score-28 (DAS28) score >5.1, is used as a cutoff value for the use of biologics in many countries, including Korea. This study compared the DAS28-erythrocyte sedimentation rate (ESR) and DAS28-C-re-active protein (CRP) to determine if these indices can be used interchangeably in patients with high disease activity.
Methods
This cross-sectional study enrolled 1,117 patients with rheumatoid arthritis and examined the initial registration data from the Korean Biologics Registry.
Results
In general, DAS28-CRP showed an excellent correlation with DAS28-ESR (r2=0.889, p <0.001). On the other hand, DAS28-CRP tended to underestimate the disease activity in those with moderate-to-high disease activity. The best agreement between DAS28-ESR and DAS28-CRP for defining a high disease activity was achieved using a cutoff value of 4.5 for the latter (kappa, 0.68; sensitivity, 85.9%; specificity, 88.1%).
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Figure 1.
(A) Scatter plot showing the DAS28-ESR and DAS28-CRP scores in this population. Each dot represents the score for a single patient. Bars represent the mean±standard deviation, which is 5.7±1.1 for DAS28-ESR and 5.0±1.1 for DAS28-CRP. (B) Distribution of disease activity as defined by the DAS28-ESR and DAS28-CRP. DAS28-ESR: 73.8% of patients had high disease activity, 24.4% had moderate disease activity, 1.5% had low disease activity, and 0.8% were in remission. DAS28-CRP: 43.0% of patients had high disease activity, 51.1% had moderate disease activity, 2.9% had low disease activity, and 3.0% were in remission. DAS: disease activity score, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein.
Figure 2.
(A) Scatter plot showing DAS28-ESR (x axis) versus DAS28-CRP (y axis) values along with a regression line. The slope and inter-cept of the regression line were 0.9427 and −0.4004, respectively. Each point represents a single patient, and the scatter lines indicate the 95% confidence interval. (B) Bland-Altman plot of DAS28-ESR and DAS28-CRP. The difference between DAS28-CRP and DAS28-ESR scores (y axis) versus the mean value for DAS28-CRP and DAS28-ESR (x axis) is shown. The mean difference is represented by the central line, and the upper and lower dashed lines represent ±1.96 standard deviation (SD) from the mean. The mean DAS28-ESR minus DAS28-CRP was 0.73, suggesting that the DAS28-CRP underestimates the overall disease activity in those with moderate-to-high disease activity. DAS: disease activity score, ESR: erythrocyte sedimentation rate, CRP: C‐reactive protein.
Table 1.
Demographics and disease characteristics of the 1,117 patients with rheumatoid arthritis
Table 2.
Comparison of DAS28-ESR and DAS28-CRP: sensitivity, specificity, and kappa coefficient values according to the cutoffs used to define high disease activity
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