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Workshop 2 Optimised use of DAS 28 in daily clinical practice

Workshop 2 Optimised use of DAS 28 in daily clinical practice. Dr Di Romana. DAS 28 A validated index. DAS 28 – a validated index. Main reasons for introduction of a standardised scoring system for RA disease activity were:

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Workshop 2 Optimised use of DAS 28 in daily clinical practice

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  1. Workshop 2Optimised use of DAS 28 in daily clinical practice Dr Di Romana

  2. DAS 28A validated index

  3. DAS 28 – a validated index • Main reasons for introduction of a standardised scoring system for RA disease activity were: • Need for uniformity in the interpretation of RA clinical trial data • Follow up of individual patients • DAS was introduced in 1983 (originally, 44 articulations were scored) • DAS 28, apart from other parameters, scores tenderness and swelling in a limited number of joints • DAS 28 is fast, easy to use and as valid as more comprehensive joint counts • Its validity is based on a balanced distribution of the weight of its components over their range between minimal and maximal scores • Change in disease activity (DAS) over time compared to baseline allows estimation of response (EULAR response criteria)

  4. DAS 28 – a validated index Weight of components DAS 28 ESR = 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.70*Ln(ESR) + 0.014*VAS DAS 28 CRP = 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.36*ln(CRP+1) + 0.014*VAS + 0.96 Range TJC: 0-28 Range SJC: 0-28 Range ESR: 1-84 Range CRP: 0-84 Range VAS: 0-100 Value needed for 1st DAS point: TJC: 4 SJC: 13 ESR: 5 CRP: 16 VAS: 72 • VAS, often considered as a too subjective component, has a low weight in the total score • Although only 28 joints are scored, DAS 28 is valid for all joints affected min-max range

  5. Validated formula's dependingon availability of data • DAS 28 ESR 4 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.70*Ln(ESR) + 0.014*VAS • DAS 28 ESR 3 (no VAS) 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.70*Ln(ESR)]*1.08 + 0.16 • DAS 28 CRP 4 (CRP) 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.36*ln(CRP+1) + 0.014*VAS + 0.96 • DAS 28 CRP 3 (CRP, no VAS) 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.36*ln(CRP+1)]*1.10 + 1.15 Note: VAS in mm ! (0-100) CRP in mg/L (lab values mostly given in mg/dL) Source: Eular handbook of clinical assessments in RA – Third edition

  6. DAS 28 – a validated index DAS 28 ESR and DAS 28 CRP DAS 28 ESR = 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.70*Ln(ESR) + 0.014*VAS DAS 28 CRP = 0.56*sqrt(TJC28) + 0.28*sqrt(SJC28) + 0.36*ln(CRP+1) + 0.014*VAS + 0.96 Range TJC: 0-28 Range SJC: 0-28 Range ESR: 1-84 Range CRP: 0-84 Range VAS: 0-100 Comparable result of DAS 28 ESR and DAS 28 CRP over the min-max range of components min-max range

  7. Linking DAS 28 and DAS 44 • The following formula allows to indirectly calculate DAS 28 values from known (historical) DAS (44) values: DAS 28 = (1,072 x DAS44) + 0,938 • Range DAS: 1-9 Range DAS 28: 2-10 Source: Eular handbook of clinical assessments in RA – Third edition

  8. DAS 28 – a validated indexPatient case 1 • Patient case: What about the feet ?

  9. Before treatment TJ : 2 SJ : 1 VS : 20 CRP : 12 VAS : 30 But : swollen feet : 4 DAS 28 VS : 3.59 CRP : 3.38 DAS 28 – a validated indexPatient case 1

  10. TJ : 2 SJ : 1 VS : 20 CRP : 12 VAS : 30 But : TJ-SJ feet : 4 DAS 28 VS : 3.59 CRP : 3.38 After treatment TJ : 1 SJ : 1 VS : 9 CRP : 5 VAS : 15 But TJ-SJ feet : 1 DAS 28 VS : 2.59 CRP : 2.66 DAS 28 – a validated indexPatient case 1

  11. TJ : 2 SJ : 1 VS : 20 CRP : 12 VAS : 30 But : TJ-SJ feet : 4 DAS 28 VS : 3.59 CRP : 3.38 TJ : 1 SJ : 1 VS : 9 CRP : 5 VAS : 15 But TJ-SJ feet : 1 DAS 28 VS : 2.59 CRP : 2.66 DAS 28 – a validated indexPatient case 1

  12. DAS 28 – a validated indexDiscussion points • Is DAS 28 as valid in patients with only feet joints affected? • Can VAS and inflammatory parameters compensate for lack of a TJ and SJ score?

  13. DAS 28Disease Activity Segments

  14. DAS 28 segmentsTherapeutic goal Therapeutic goal

  15. DAS 28 segmentsLink between DAS en DIS Disease activity > 3.2 Joint damage Disability Keeping DAS 28 below 3.2 prevents progression of joint damage (1,3) (2,3) (1) Smolen 2004 – Ann Rheum Dis 63: 221-225 (2) Scott 2000 – Rheumatology 39: 122-132 (3) Welsing 2001 – Arthritits Rheum 44: 2009-2017

  16. DAS 28 segmentsDistribution of RA patients Undertreated ? Roche market research – data on file – data collection period: 2006

  17. DAS 28 segmentsPatient case 2 • Patient Case: Can the therapeutic goal be reached in all patients ?

  18. TJ : 13 SJ : 14 VS : 32 CRP : 52 VAS : 72 DAS 28 VS : 6.50 CRP : 6.46 DAS 28 segmentsPatient case 2 Patient Case: Can the therapeutic goal be reached in all patients ?

  19. TJ : 13 SJ : 14 VS : 32 CRP : 52 VAS : 72 DAS 28 VS : 6.50 CRP : 6.46 DAS 28 segmentsPatient case 2 Patient Case: Can the therapeutic goal be reached in all patients ? TJ : 5 SJ : 3 VS : 18 CRP : 23 VAS : 38 DAS 28 VS : 4.29 CRP : 4.37

  20. EULAR response criteria Source: Eular handbook of clinical assessments in RA – Third edition

  21. DAS 28 segmentsDiscussion points • Should all patients with DAS 28 values above 3.2 be treated more aggressively? • What is to be preferred: a DAS 28 of lower than 3.2 but relatively high inflammatory parameters, or a DAS 28 of higher than 3.2 although inflammatory parameters are low? • Or should we never look at the individual components and only consider the absolute value of DAS 28? It’s a validated index after all… • Should we first be convinced “clinically” that treatment needs to be adapted, before we believe what DAS 28 tells us?

  22. DAS 28Snap shot versus Trend

  23. Snap shot versus TrendEvolution of DAS 28 over time • DAS 28 evaluates disease activity at a specific point in time: a snap shot... • However, DAS 28 can fluctuate over time • These fluctuations can be influenced by more factors than RA disease activity • Emotional factors (influencing VAS) • Non-inflammatory pain (influencing TJC) • Presence of infection (influencing ESR/CRP)

  24. Snap shot versus TrendEvolution of DAS 28 over time Treatment change Treatment change ??

  25. Snap shot versus TrendPatient case 3 • Patient case: Snap shot or Trend? TJ : 1 SJ : 1 VS : 8 CRP : 3 VAS : 9 DAS 28 : 2.4 TJ : 7 SJ : 1 VS : 11 CRP : 5 VAS : 96 DAS 28 : 4.79

  26. Snap shot versus TrendPatient case 3 • Patient case: Snap shot or Trend? TJ : 1 SJ : 1 VS : 8 CRP : 3 VAS : 9 DAS 28 : 2.4 TJ : 6 SJ : 6 VS : 20 CRP : 22 VAS : 46 DAS 28 : 4.79

  27. Snap shot versus TrendDiscussion points • Always systematically exclude confounding factors or are they less confounding than we assume? • Measure DAS 28 systematically at regular time intervals, allowing detection of a disease activity trend? • Does a trend tell us more than a single value? • Use electronic tools that allow us to follow DAS 28 as well as the individual components over time in a user-friendly way? (Disease Activity “Dashboard”)

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