|Year : 2017 | Volume
| Issue : 2 | Page : 68-69
Outcome assessment in rheumatoid arthritis: The patient says the best
Durga Prasanna Misra, Vikas Agarwal
Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||26-May-2017|
Durga Prasanna Misra
Department of Clinical Immunology, C-Block, 2nd Floor, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareily Road, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Misra DP, Agarwal V. Outcome assessment in rheumatoid arthritis: The patient says the best. Indian J Rheumatol 2017;12:68-9
Patients with rheumatoid arthritis (RA) form a majority of attendees at rheumatology clinics worldwide and are prone to develop deformities due to damage resulting from inadequately treated disease. They are treated with a variety of conventional and biologic disease modifying anti-rheumatic drugs (DMARDs) which have associated toxicities. Balancing the need to further intensify immunosuppression versus avoidance of excessive medical therapy is a challenge for the Rheumatologist. Herein lies the importance of assessing disease activity. Various disease activity measures, clinical and radiologic, used in clinical practice have evolved in parallel with the armamentarium of drugs available to treat RA.
The most popular tool used to assess disease activity in RA is the composite disease activity score (DAS). The original DAS score required a 44-joint swollen joint count, the 53-joint Ritchie articular index (assessing tenderness) with the erythrocyte sedimentation rate and a patient global assessment (PGA). This was simplified further to the DAS score using 28-joint count (DAS28), which substituted the two former variables for a 28-joint tender and swollen joint count. The simplified disease activity index (SDAI) and clinical disease activity index (CDAI) are other commonly used composite disease activity tools. All these scores define cutoffs for remission, low disease activity, moderate disease activity, and high disease activity. The American College of Rheumatology (ACR) and the European League Against Rheumatism have proposed a definition for remission to be used in clinical trials, which require the presence of no more than one tender joint and one swollen joint with a serum C-reactive protein level up to 1 mg/L and PGA ≤1 (Boolean definition), or SDAI ≤3.3 (Index-based definition). The ACR has also proposed ACR20, ACR50, and ACR70 as outcome measures for use in the setting of clinical trials. Of late, patient-reported outcomes such as the Rapid Assessment of Patient Index Data and RA Disease Activity Index 5 have gained significant attention. The latter is a simple tool utilizing five questions assessing the extent of pain, swelling, and stiffness at present and over the past 6 months, scored from 0 to 10. In the present issue of the journal, Singh et al. describe the utility of this simple patient reported outcome measure in a busy outpatient clinic at a tertiary care referral hospital in India and validate its utility in this setting when compared with other established outcome measures such as DAS28 and CDAI. Other patient-related outcomes include the online Patient Related Outcomes Measurement Information System – Physical Function, which has been shown to perform better in patients with RA than existing scores such as Health Assessment Questionnaire Disability Index or the WHO Short form-36. However, even these scores do not capture fatigue, an important component of disease activity. Imaging-based scoring systems utilize either conventional radiographs (e.g., modified Sharpe van der Heidje score assessing joint space narrowing and erosions) or advanced imaging modalities such as ultrasound to assess synovitis (GS-7 score) or magnetic resonance imaging (MRI) to assess synovitis and erosions (RAMRIS score).
With this background, the next question for the clinician is which of these indices is the best to use? Clinical DAS and patient-reported scores have a significant advantage over imaging-based scores because of easier practical applicability in the clinic. Between these clinical scores, it is up to the clinician to utilize whichever score they are best acquainted with, as none of these is definitely better than the other. It is important to understand that irrespective of whichever scoring system is used, one must use a treat-to-target (TTT) strategy, wherein the target is either low disease activity or remission (not just remission). The landmark TICORA trial which pioneered the concept of TTT achieved an ACR70 response in >70% participants utilizing only conventional DMARDs, something which even trials with biologic DMARDs have failed to achieve. The utility of imaging-based disease activity assessment in the follow-up of patients with RA needs further confirmation in view of the inability of two recent trials , to demonstrate a significant advantage of the use of ultrasound and MRI when compare with a clinical TTT approach. In our experience, often the simplest but most effective way of knowing the overall impact of the disease (inclusive of fatigue) in a patient with RA is to ask a simple question, i.e., how many Paise out of one Rupee do you feel better when compared with the time you were started on medications for the first time? Patient-reported outcomes have the advantage of actively involving the patient in the decision-making process and may help best optimize the pharmacotherapy of these patients who often require lifelong therapy.
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