Patient-centered psoriatic arthritis (PsA) activity assessment by Stockerau Activity Score for Psoriatic Arthritis (SASPA).

BACKGROUND: To investigate whether a modified Rheumatoid Arthritis Disease Activity Index-5 could be applied as a routine assessment tool for psoriatic arthritis (PsA) patients. METHODS: Ninety-seven PsA outpatients (mean age 49.78 years; age range 23-80 years; 49 male, 48 female), completed a prototype questionnaire. Tender and swollen joint counts, including enthesiopathy, physician's assessment of disease activity on a visual analog scale (MDglob), erythrocyte sedimentation rate, and patient satisfaction with disease status (PatSat: 1 = excellent to 5 = unsatisfactory) were recorded. Factorial analysis was performed and alpha, as a measure of reliability, and tau were calculated. The ultimate five-item questionnaire, calculated by (Q1 + Q2 + Q3 + Q4 + Q5)/5, was then handed over to 152 PsA outpatients (mean age 54.02 years; age range 26-80 years; 82 male, 70 female), and analyzed accordingly. RESULTS: Analyzing the internal consistency of the prototype questionnaire revealed the highest alpha value of 0.849, on deleting the question targeting disease course. Alpha for the final Stockerau Activity Score for Psoriatic Arthritis (SASPA) was 0.875, with all items contributing to the final result (item loading from 0.573 to 0.910). Kendall's tau for the relationship between SASPA scores and swollen joint count, tender joint count, and MDglob was 0.34, 0.416, and 0.392, respectively. The sensitivity of the questionnaire to change was demonstrated in patients starting treatment with a tumor necrosis factor blocker (standardized mean difference: 2.1). CONCLUSION: The SASPA questionnaire constitutes a fully patient-administered tool to monitor PsA activity. Its reliability, convergent validity, and sensitivity to change were demonstrated.

Remission in rheumatoid arthritis: a comparison of the 2 newly proposed ACR/EULAR remission criteria with the rheumatoid arthritis disease activity index-5, a patient self-report disease activity index.

OBJECTIVE: We analyzed whether a patient self-report remission criterion, such as that according to the Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), meets the criteria of the 2011 proposed American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) definition of remission. METHODS: The 2 approaches of the ACR/EULAR proposal [Boolean- and Simplified Disease Activity Index (SDAI)-based] as well as the RADAI-5 were used to assess whether patients with RA are in remission. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), and kappa analyses were performed to illustrate the relationship among the different approaches defining remission at a group level. RESULTS: In total, 705 patients' assessments were included. Eighty-nine patients were classified as being in remission according to the Boolean-based and 169 according to the SDAI-based definition of the ACR/EULAR proposals, and 154 according to the RADAI-5. Sixty-eight assessments were classified as being in remission according to all 3 definitions. In the case of RADAI-5 remission, sensitivity was 78%, specificity 86%, PPV 45%, and NPV 96%, indicating remission according to the Boolean-based definition; and 60%, 92%, 66%, and 90%, respectively, indicating remission according to the SDAI-based definition. In the case of remission according to the SDAI-based ACR/EULAR definition, sensitivity was 52%, specificity 100%, PPV 98%, and NPV 87%, also indicating remission according to the Boolean definition; while according to the Boolean definition the values were 98%, 87%, 52%, and 100%, respectively. Kappa statistics showed fair to good agreement for all 3 definitions. CONCLUSION: Nearly twice as many assessments were classified as being in remission using the SDAI-based or the RADAI-5 definitions when compared to the Boolean-based definition. Remission according to the RADAI-5 also was highly specific for both ACR/EULAR criteria. Sensitivity for the RADAI-5 criterion was even better for the Boolean-based definition than that for the SDAI-based definition.

A comparison of patient questionnaires and composite indexes in routine care of rheumatoid arthritis patients.

OBJECTIVE: To evaluate the agreement between the Routine Assessment of Patient Index Data 3 (RAPID-3) and a modified version of the Rheumatoid Arthritis Disease Activity Index (RADAI-5), as well as the Disease Activity Score including a 28 joint count (DAS28-ESR) and the Clinical Disease Activity Index (CDAI) in daily routine. METHODS: One hundred and twenty-eight rheumatoid arthritis (RA) out-patients completed the RADAI-5 and the RAPID-3. Simultaneously, the DAS28-ESR and the CDAI were applied. Cronbach's Alpha as a measure for reliability was calculated and factorial analysis was performed. For agreement analysis, Kendall's Tau was calculated. RESULTS: Time to score the questionnaires was 25seconds. The median RADAI-5 was 2.8 (0-9.2), the median RAPID-3 3.3 (0-8.6), the median DAS28-ESR 2.95 (0.43-6.24), and the median CDAI 5.6 (0-37.5). Cronbach's Alpha for the RADAI-5 was 0.906 and 0.871 for the RAPID-3, however, only 0.165 for the DAS28-ESR and 0.210 for the CDAI, respectively. Factorial analysis revealed that both questionnaires and the DAS28-ESR, but not the CDAI, constitute mono-dimensional instruments. Tau for the agreement between the RADAI-5 and the RAPID-3 appeared to be 0.587 (p<0.001), and to be 0.582 (p<0.001) between the DAS28-ESR and the CDAI, while it was lower for the relationship between the questionnaires and the composite indexes. CONCLUSION: Reliability of the RAPID-3 and RADAI-5 was significantly higher than of the indexes. The questionnaires as well as the indexes proved to be in highly moderate agreement, while agreement between the questionnaires and the indexes appeared to be lower.

The rheumatoid arthritis disease activity index-5 in daily use. Proposal for disease activity categories.

OBJECTIVE: To establish thresholds for rheumatoid arthritis (RA) activity categories according to the RA Disease Activity Index-5 (RADAI-5). METHODS: Three hundred ninety-two patients with RA were categorized according to Disease Activity Score 28-joint count (DAS28), Clinical Disease Activity Index (CDAI), and their satisfaction (PATSAT) with disease status. These measures built the basis for the calculation of disease activity limits for the RADAI-5. Patient assessments simultaneously meeting the identical DAS28, CDAI, and PATSAT categories were taken as the references to establish the thresholds for the respective RADAI-5 categories by calculating the third quartile of the corresponding RADAI-5 values. Subsequently, these new thresholds were applied to all assessments. RESULTS: Seven hundred fifty-eight assessments in 392 patients (2 assessments median/patient) could be obtained, most patients having mild to moderate disease according to DAS28 and CDAI. Calculating the third quartile, the RADAI-5 thresholds were as follows: 0.0-1.4 for a remission-like state, 1.6-3.0 for mild disease activity, 3.2-5.4 for moderate, and 5.6-10.0 for high disease activity. Categorization according to the RADAI-5 showed a normal distribution, while DAS28 and CDAI were somewhat shifted to the left. DAS28 and CDAI levels, as well as tender and swollen joint counts and physician's global assessment and erythrocyte sedimentation rate, proved to be highly significantly different within the different RADAI-5 categories (Kruskal-Wallis test p < 0.001). CONCLUSION: RADAI-5 thresholds for RA activity could be elaborated. Patient self-report questionnaires may substitute composite disease activity scores and may contribute significantly to improving documentation in routine patient care.

Patient-centered rheumatoid arthritis disease activity assessment by a modified RADAI.

OBJECTIVE: To evaluate the psychometric properties and validity of a modified version of the Rheumatoid Arthritis Disease Activity Index (RADAI) without joint counts in order to facilitate rapid and easy RA activity assessment in daily routine. METHODS: One hundred sixty-nine outpatients with RA completed the original RADAI and the modified RADAI-5. Simultaneously, the Disease Activity Score-28-erythrocyte sedimentation rate (DAS28-ESR) and C-reactive protein (DAS28-CRP) and the Simplified Disease Activity Index (SDAI) and Clinical DAI (CDAI) were applied. Cronbach's alpha, as a measure for internal consistency, and Spearman's rho, to evaluate the linear relationship of the different disease activity scales, were calculated. Rho was determined for the RADAI-5 and the core set measures to assess convergent validity. For agreement analysis, kappa statistics were calculated. An attempt was made to estimate the modified questionnaire's sensitivity to change. RESULTS: Means for the RADAI and the RADAI-5 were 2.8 (range 0.0-9.12) and 3.07 (0-10), respectively. Other means were as follows: DAS28-ESR 3.51 (0.28-6.67), DAS28-CRP 3.19 (1.12-5.83), CDAI 11.53 (0.0-44.6), and SDAI 12.36 (0.1-44.9). Cronbach's alpha was highest for the RADAI-5 (0.917) and lowest for the DAS28-CRP (0.510). The RADAI-5 was highly significantly correlated (all p < 0.0001) to all other instruments. However, kappa was < 0.65 for the relation of the RADAI-5 and all other scores except the RADAI. Changes of the RADAI-5, DAS28-ESR, and CDAI were significantly correlated (p < 0.001). CONCLUSION: The RADAI-5, refraining from joint counts, was shown to be capable of measuring RA activity. Reliability and convergent validity could be proven.

Immunization of patients with rheumatoid arthritis with antitumor necrosis factor alpha therapy and methotrexate.

PURPOSE OF REVIEW: The aim of this study is to highlight the recent findings on the use of methotrexate and/or TNFalpha-blockers in adult patients with rheumatoid arthritis and their effects on the immune response to various vaccines. RECENT FINDINGS: Regarding influenza vaccination, methotrexate monotherapy is not associated with a decreased response, whereas the use of etanercept and infliximab in combination with methotrexate may cause lower titers and lower response rates. Concerning pneumococcal vaccination, methotrexate seems to impair responsiveness. The concomitant use of adalimumab and methotrexate is also associated with decreased response, whereas the concomitant use of etanercept or infliximab seems not to have an effect on response rates. As immunological pathways seem to play a major role, T-cell-dependent pneumococcal vaccines are designed to achieve higher response rates and protective titers. SUMMARY: Patients with rheumatic disorders are more likely to develop preventable infectious diseases, which underlines the importance of adequate immunoprotective titers. Several studies have shown that the combination of methotrexate and certain TNFalpha-blockers are affecting the responsiveness to vaccines. Further findings indicate that the response also depends on what type of vaccine is used.

Disease activity score-28 values differ considerably depending on patient's pain perception and sex.

OBJECTIVE: To determine if the Disease Activity Index including a 28-joint count (DAS28) is equally applicable for the total population with rheumatoid arthritis (RA). METHODS: Five hundred fifty-seven outpatients with RA [432 women, 125 men; median age 64 yrs (range 0-85), median disease duration 48 mo (range 2-548)] were enrolled consecutively into this cross-sectional study. DAS28, physician's global assessment of disease activity, patient's assessment of pain on visual analog scale, C-reactive protein (mg/dl), rheumatoid factor (RF), and disease duration were recorded. t-tests were applied for all comparisons of DAS28 values. Linear regression analysis was performed for each confounding factor. RESULTS: The mean DAS28 in female patients was 3.66 +/- 0.57 SEM, and in males 3.01 +/- 1.12 (p < 0.001). DAS values in patients with early RA (< 37 mo) were significantly higher than in patients with advanced RA (3.62 +/- 0.67 vs 3.37 +/- 0.81, respectively; p < 0.017). Regression analysis revealed a highly significant relationship between DAS28 score and patient's pain rating (r = 0.592, p < 0.0001). Pain exerted the greatest influence on the DAS28 (p < 0.0001), while of the other factors only age (p < 0.008 for females, p < 0.007 for males) was also significantly correlated with the DAS28 values. CONCLUSION: DAS28 values differ considerably depending primarily on the patient's pain perception and gender and to a lesser degree on patient's age, whereas results for disease duration and RF were inconclusive.