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Is show to have the best impact on containing and treating RA.
Systematic DAS-Driven Therapy May Improve Outcomes in Rheumatoid Arthritis CME
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
CME Released: 01/04/2010; Valid for credit through 01/04/2011
January 4, 2010 — In patients with recent-onset rheumatoid arthritis receiving traditional treatment, treatment systematically driven by Disease Activity Score (DAS) was associated with significantly better clinical improvement and possibly with reduced progression of joint damage, according to the results of a study reported in the January 2010 issue of Annals of the Rheumatic Diseases.
"This study provides further evidence in support of the data that objective assessment of rheumatoid arthritis disease activity and using a goal to achieve a target disease activity state (such as low disease activity state or remission) to make therapeutic decisions leads to significant improvement in clinical outcomes for rheumatoid arthritis patients," Nasim A. Khan, MD, assistant professor of rheumatology at the University of Arkansas for Medical Sciences in Little Rock, told Medscape Rheumatology when asked for independent comment. "Unfortunately, most patients with rheumatoid arthritis in routine clinical care are not evaluated objectively for disease activity, and treatment decisions are made based on gestalt impressions of the treating doctor. This study provides further impetus to change such practices to improve clinical outcomes for rheumatoid arthritis patients."
The goal of this study, by Y.P.M. Goekoop-Ruiterman, from Leiden University Medical Centre in Leiden, the Netherlands, and colleagues, was to compare the efficacy of treatment systematically driven by DAS vs routine care in patients with recent-onset rheumatoid arthritis. Participants were receiving traditional antirheumatic therapy from either the BeSt study, a randomized controlled trial comparing different treatment strategies (group A; n = 234), or from 2 Early Arthritis Clinics (group B; n = 201).
Patients in group A had systematic, DAS-driven treatment adjustments aiming to achieve low disease activity, defined as DAS ≤ 2.4. Physician judgment determined treatment of patients in group B. Outcomes included functional ability measured with the Health Assessment Questionnaire (HAQ), Disease Activity Score in 28 joints (DAS28), and Sharp/van der Heijde radiographic score (SHS).
Demographic characteristics were similar in both groups, and mean baseline HAQ was 1.4. Compared with group B, group A had a longer median disease duration (0.5 vs 0.4 years; P = .016), higher mean DAS28 (6.1 vs 5.7; P < .001), more patients who tested positive for rheumatoid factor (66% vs 42%; P < .001), and more patients with erosions (71% vs 53%; P < .001).
After 1 year, mean HAQ improvement was 0.7 in group A and 0.5 in group B (P = .029), and the percentage in remission, defined as a DAS28 of less than 2.6, was 31% vs 18% (P <. 005), respectively. Median SHS progression in group A was 2.0 vs an expected progression of 7.0. In group B, median SHS progression was 1.0 vs an expected progression of 4.4.
"In patients with recent-onset rheumatoid arthritis receiving traditional treatment, systematic DAS-driven therapy results in significantly better clinical improvement and possibly improves the suppression of joint damage progression," the study authors write.
Strengths of this study noted by Dr. Khan are that 1-year follow-up data on all outcomes of interest were available for the vast majority of the study patients, DAS assessment was performed by trained research nurses, and radiographic progression assessment was done independently by 2 readers blinded to treatment group and sequence of films.
However, Dr. Khan also noted several study limitations.
"Despite similar enrollment criteria, the DAS-driven therapy group and routine care group differed significantly upon baseline assessment in rheumatoid arthritis disease activity and adverse prognostic factors (RF-positivity and radiographic joint damage)," he said.
Dr. Khan also noted significant differences in the medications received by patients in the 2 groups. Patients in the routine care group less often received methotrexate and more often received low-dose prednisone.
"Furthermore, it is not clear whether disease activity assessment by DAS or DAS28 was available or performed by the treating doctor at the time of therapeutic decision for the patients in the routine care group," Dr. Khan added. "These factors may have masked the true impact of DAS-driven therapy compared to routine care."
When asked about additional research needed, Dr. Khan pointed out that the 6 available indices of rheumatoid arthritis activity should be compared with one another. The American College of Rheumatology 2008 recommendations for the use of disease-modifying antirheumatic drugs suggest using any of the 6 indices to assess rheumatoid arthritis disease activity, but some of these indices have, at best, a moderate agreement with one another.
"While objective assessment of RA [rheumatoid arthritis] disease activity is important, it remains unclear which of the several indices that have been developed and validated for this purpose is optimum for patient care," Dr. Khan concludes. "Further research is needed to clarify the comparative utility and interchangeability of these indices and impact of factors such as comorbidity burden on rheumatoid arthritis activity assessment. Also, further studies are needed for the long term clinical effect of the radiographic progression observed with current treatments."
The Dutch College of Health Insurances (College Voor Zorgverzekeringen) funded this study, with additional funding provided by Schering-Plough, BV, and Centocor. Some of the study authors have disclosed various financial relationships with Schering-Plough. Dr. Khan has disclosed no relevant financial relationships.
Ann Rheum Dis. 2010;69:65-69. Abstract
Clinical Context
Rheumatoid arthritis is a very debilitating disease; therefore, treatment is of utmost importance in the disease process. According to the BeSt study, four different treatment strategies for rheumatoid arthritis were compared. Patients treated with initial combination therapy with either prednisone or infliximab had a more rapid clinical response than patients treated with sequential monotherapy or step-up to combination therapy. After 1 year, changes in the physical function and the percentage of patients in clinical remission were comparable; however, to achieve this, treatment was adjusted for more patients in the initial monotherapy groups vs the initial combination therapy groups.
The aim of this study was to compare the efficacy of DAS-driven therapy and routine care in patients with recent-onset rheumatoid arthritis.
Study Highlights
* In this study, patients with recent-onset rheumatoid arthritis receiving traditional antirheumatic therapy from either the BeSt study, a randomized controlled trial comparing different treatment strategies (group A), or 2 Early Arthritis Clinics (group B) were included.
* All patients fulfilled the American College of Rheumatology 1987 criteria for rheumatoid arthritis.
* In group A, systematic DAS-driven treatment adjustments aimed to achieve low disease activity (DAS ≤ 2.4).
* In group B, the treatment, including the use of corticosteroids and biological agents, was left to the discretion of the treating clinician.
* Functional ability (HAQ) was the primary endpoint, with higher scores indicating more severe loss of physical function. DAS28 and SHS radiographic score were also evaluated.
* Results demonstrated that at baseline, patients in group A (n = 234) and group B (n = 201) had comparable demographic characteristics and a mean HAQ of 1.4.
* Group A had a longer median disease duration than group B (0.5 vs 0.4 years; P = .016), a higher mean DAS28 (6.1 vs 5.7; P < .001), more patients who tested positive for rheumatoid factor (66% vs 42%; P < .001), and more patients with erosions (71% vs 53%; P < .001).
* Overall, clinical outcomes had improved after 1 year. The mean HAQ improvement was 0.6, the mean DAS28 improvement was 2.4, and the mean decrease in erythrocyte sedimentation rate decrease was 15 millimeters per hour.
* After 1 year, the HAQ improvement was 0.7 vs 0.5 (P = .029), and the percentage in remission, defined as a DAS28 of less than 2.6, was 31% vs 18% (P < .005) in groups A and B, respectively.
* In group A, the median SHS progression was 2.0 (expected progression, 7.0); in group B, the SHS progression was 1.0 (expected progression, 4.4). The larger difference between the expected progression and observed progression in group A suggests that the suppression of joint damage progression was better in this group vs group B; however, this was not statistically significant (P = .126).
* At baseline, significantly more patients in group A had erosive disease (71% vs patients in group B, 53%; P < .001). After treatment for 1 year, the difference in percentage of patients with erosive disease was less distinct (group A, 81%; group B, 74%; P = .091).
Clinical Implications
* According to the BeSt study, patients with recent-onset rheumatoid arthritis treated with initial combination therapy with either prednisone or infliximab had a more rapid clinical response than patients treated with sequential monotherapy or step-up to combination therapy.
* Compared with traditional treatment, systematic DAS-driven therapy results in significantly better clinical improvement and possibly improves the suppression of joint damage progression in patients with recent-onset rheumatoid arthritis.
how to be a velvet bulldoser
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Rank: Advanced Member  Groups: Registered
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Thankyou Jenni lot good info there melly cuddly cats make my world seem so much more fun
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Rank: Advanced Member  Groups: Registered
Joined: 12/3/2009 Posts: 3,006 Location: Timperley
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Thank for this, Jenni. I suppose when you think about it all logically, therapy driven by DAS scores has to be the best way forward. This way, they actually take into account how we feel, how our joints feel and don't just go on blood tests etc. as seems to be the norm in so many cases. Good article.
Lots of love
Jeanxxxx
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Rank: Advanced Member  Groups: Registered
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Thanks Jenni - really interestinng.
Julie
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Rank: Advanced Member  Groups: Registered
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Hi Alhtough Interesting i found it very hard to focus on reading so I read the summation which in the end said that there was only a small difference after 1st year. I go to an early rheumatiod clinic and I have never seen my das score. but the doc takes into consideration how i am doing as well as bloods. So isnt this the same as das driven therapy? Has anyone had a das score done and have their card marked up. Oh and didnt clinton come from Little Rock Arkansas too  thanks for posting Jenni 
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Thanks for this Jenni,
as far as i know ive not had a DAS score - am going to ask about this at next clinic - all my useful info about this has come from you guys and NRAS so thank yOU XXX
Love Liz xxxxx
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In the 39 years I've had RA, its only during the last couple of years my new, much younger, Rheumatologist has given me a DAS score. Prior to that some doctors made comments like, "the disease may have burnt itself out". Absolute rubbish, as they found out last year when I wasn't allowed any meds! I don't have a DAS record book. BTW I was told some joints are discounted in a DAS score, think its toes, but fingers, knuckles etc. count? Carol
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Rank: Advanced Member Groups: Registered
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it is yrs since I had a DAS.
It is hands and feet. it used to annoy me as I was having knee and shoulder prbs at the time!
Jenni xxhow to be a velvet bulldoser
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Rank: Advanced Member  Groups: Registered
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Thank you Jenni, I found this article very interesting, after having this illness coming up to nearly a year now, I still consider myself to be newly diagnosed. I was given mono-treatment at first, then with a combination of steroids, and then due to liver problems, I was taking steroids only. I was advised to stop the steroids due to a growth in my Adrenal gland, and was given Naproxen, but then told to stop that too, because of the Adrenal tests, so I'm now taking naught!! Anyway, I was recently assessed for Anti-TNF and under went a DAS 28 assessment. I was told that my disease was active, I felt like saying "you're not kidding" as if I didn't know! What I found really strange is that they don't take the ankles and feet into consideration  . Can anyone tell me why? I have erosions on my toes, my feet and ankles swell, hurt and are stiff, and find not being able to walk without pain very debilitating. Love, Barbara XXXXXX
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Yes I remember that Carol! they would always say that if you were DX before 18 or so, it *may* burn itself out...how many times did we hear that!
Love,
Amanda
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Hi Amanda,
My nephew has RA and was diagnosed in his early teens, he is now 32 and still has RA!
Love,
Barbara
XXXXX
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barbara-o wrote:What I found really strange is that they don't take the ankles and feet into consideration . Can anyone tell me why? I have erosions on my toes, my feet and ankles swell, hurt and are stiff, and find not being able to walk without pain very debilitating. Love, Barbara XXXXXX I'd like to know this too Barbara. DAS 28 score, does that mean they assess 28 joints? But exactly which ones, must be the same for everyone? My Rheumatology Nurse, formerly a physio, told me they don't include toes and feet (maybe because there are lots of joints in feet) and she showed me the "DAS calculator" and worked out my score (number of painful/swollen joints, ESR etc.) in my presence. Carol
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amanda_lewin wrote:Yes I remember that Carol! they would always say that if you were DX before 18 or so, it *may* burn itself out...how many times did we hear that!
Love,
Amanda If only Amanda!  Carol
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Ive had this done only with new RA clinic dont recall old rheumy from newmarket doing this,maybe he did to young to remember that far abck lol age 17. umm makes me sound anceint. anyhow new rheumy done it few times only checked hands wrists joints thats it. and then a questionaire and timeline for scale of pain. last 1 done last Febuary. currently not doing them with me as under investigation as to whetehr Lupus well sle or RA or both. do however still check my joints currently guessing im lucky get all joints checked at each appointment. also soft tissue now checked due to fibromalgia doagnosed november. counting myself lucky im getting somewhere at least. just pray was same care level for you lovely lot. melly cuddly cats make my world seem so much more fun
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Rank: Advanced Member Groups: Registered
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My DAS score is evaluated at every appointment.
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So is mine! But this is a recent move, ie last few years!
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Rank: Advanced Member  Groups: Registered
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Thanks for this Jenni- very informative. I don't think I've had a DAS assessemnt- or if I have, I don't know about it.
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Hi
I have had my DAS score done bi-monthly over the last 18 months
Albertxxxxx
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