Know the Disease Activity Score and stay one step ahead of rheumatoid arthritis
A Disease Activity Score (DAS) can be used to assess patients’ rheumatoid arthritis (RA) disease activity, to determine whether it is under control and if any treatment adjustments are required. It can also assist in establishing a target score to aim for, to help inform treatment decisions and optimise disease management.
DAS28 is a composite outcome measure that assesses:
• How many joints in the hands, wrists, elbows, shoulders, and knees are swollen and/or tender
• The erythrocyte sedimentation rate (ESR) or C reactive protein (CRP) in the blood to measure the degree of inflammation
• The patient’s Visual Analogue Score (a simple scale) to assess how they are feeling on that day from 0 (very good) to 10 (very bad)
The results are combined to produce the DAS28 score, which correlates with the extent of disease activity:
• < 2.6: Disease remission
• 2.6 – 3.2: Low disease activity
• 3.2 – 5.1: Moderate disease activity
• >5.1: High disease activity
A score of less than 2.6, classified as ‘remission’, is the ultimate goal for patients with RA, though it’s important to recognise that not everyone can achieve this.i However, the vast majority of patients can, if treated early and appropriately, achieve DAS disease remission or low disease activity, which will bring about a great improvement, long-term, to their quality of life.
National guidelines* state that a Disease Activity Score (DAS) assessment should be carried out at least twice a year. However, good practice dictates that a DAS assessment should be undertaken at every consultation, allowing for RA symptoms to be regularly assessed and treatment adapted as necessary, to ensure that the disease is kept tightly controlled and remission is achieved in as many patients as possible. For those patients who are recently-diagnosed with RA, a DAS assessment should be conducted every month, until treatment has controlled disease activity to a level agreed with the patient.ii,iii
• The National Institute for Health and Clinical Excellence guidelines “Rheumatoid arthritis: The management of rheumatoid arthritis in adults” (issued February 2009) can be found at: http://www.nice.org.uk/guidance/CG79/chapter/introduction
• The British Society for Rheumatology guidelines ‘British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (after the first 2 years)’ can be found at: https://goo.gl/mnOhj2
Clinical paper of interest
• Fransen J and LCM van Riel P. Outcome measures in inflammatory rheumatic diseases. Arthritis Research & Therapy 2009, 11:244
“DAS28 allows us to monitor and track the status of a patient’s disease activity over time, providing easily comparable data from visit to visit. This will indicate whether the disease has been effectively treated or if it has progressed, allowing us to make informed decisions about their treatment. For example, in discussion with a patient we can determine a target DAS28 to work towards. This will usually (but not always) be the lowest disease activity achievable, providing a clear goal to inform treatment decisions. The simple numerical score also facilitates open discussion with the patient, who should recognise the direct correlation between their score and their disease activity.”
- John Isaacs, Professor of Clinical Rheumatology and Director of the Wilson Horne Immunotherapy Centre at Newcastle University
“Use of DAS28 means we can maintain 'tight control' and quickly identify whether a patient’s symptoms are improving or not. It also means we can monitor how well a patient is responding to treatment, adapt their care as necessary to ensure that further pain is minimised and most importantly reduce the likelihood of further damage to their joints.”
- Colin Beevor, Senior Clinical Nurse Specialist for Rheumatology Services and Matron/ Service Manager for Musculoskeletal Services (Rheumatology, Spinal Services and Chronic Pain Clinic) at Portsmouth Hospitals NHS Trust
DAS28 and the feet
It’s important to note that assessment of the feet is not included in the DAS28. This is because joint damage in the feet may be a chronic complaint which is not due to ongoing disease activity; therefore the feet are a less accurate way of measuring a patient’s RA and response to treatment, compared to assessing joints in the hands.
Assessment of the feet should, however, be included as part of the broader consultation to ensure that the patient’s RA and well-being is optimally managed, and any problems with the feet are addressed in a timely fashion.
DAS training Video
This short film demonstrates how a DAS assessment is conducted in a clinical setting, identifying examination techniques to assess swollen and tender joints, things to look out for and observe and key questions to ask.
DAS quick reference guide
Please click here to download the 'Quick reference guide' as a PDF
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The DAS quick reference guide provides a pictorial step-by-step overview of examination techniques and the key stages of the examination to assess swollen and tender shoulder, elbow, wrist, hand and knee joints. It also provides guidance for recording results, including the ESR or CRP and the patient’s Visual Analogue Score and how this data is compiled to identify the DAS, ensuring that patients’ progress and disease states are closely monitored over time.
iJ. Fransen, P.L.C.M. van Riel. The Disease Activity Score and the EULAR response criteria. Clin Exp Rheumatol 2005;23 (Suppl.39): S93-S99
iiNational Institute for Health and Clinical Excellence. CG79 The management of rheumatoid arthritis in adults. February 2009. http://www.nice.org.uk/nicemedia/live/12131/43327/43327.pdf(Accessed October 2012)
iii British Society of Rheumatology guidelines. BSR and BHPR rheumatoid arthritis guidelines on eligibility criteria for the first biological therapy. March 2010. http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/m/management_of_
rheumatoid_arthritis_after_first_2_years.pdf (Accessed October 2012)
This is a joint collaboration between Roche Products Ltd, Chugai Pharma UK Ltd and the National Rheumatoid Arthritis Society. The development of the content of the website, including the booklets and DVDs has been funded by Roche and Chugai.
Date of preparation: February 2013