J Rheum Dis.  2016 Aug;23(4):241-249. 10.4078/jrd.2016.23.4.241.

Comparison of Disease Activity Score 28 Using C-reactive Protein and Disease Activity Score 28 Using Erythrocyte Sedimentation Rate in Assessing Activity and Treatment Response in Rheumatoid Arthritis: A Meta-analysis

• Song GG
• Lee YH

• KMID: 2352467
• DOI: http://doi.org/10.4078/jrd.2016.23.4.241

Abstract

OBJECTIVE
We compared the Disease Activity Score 28 (DAS28) using C-reactive protein (DAS28-CRP) with DAS28 using erythrocyte sedimentation rate (DAS28-ESR) in assessing rheumatoid arthritis (RA) activity and determining European League Against Rheumatism (EULAR) response criteria.
METHODS
We searched the PubMed, EMBASE, and Cochrane databases and performed a meta-analysis to examine comparisons between DAS28-CRP and DAS28-ESR by RA activity and EULAR response criteria.
RESULTS
A total of ten studies were included in this meta-analysis. Significantly more patients were classified as having remission or low disease activity when using DAS28-CRP than when using DAS28-ESR (odds ratio [OR]=1.869, 95% confidence interval [CI]=1.180 to 2.959, p=0.008; OR=1.411, 95% CI=1.256 to 1.586, p=7.0×10⁻⁸), whereas fewer patients were classified as having high disease activity when using DAS28-CRP than when using DAS28-ESR (OR=0.534, 95% CI=0.388 to 0.734, p=1.1×10⁻⁴). More patients were classified as having good response with criteria were based on DAS28-CRP than with DAS28-ESR (OR=1.390, 95% CI=1.183 to 1.632, p=6.10×10⁻⁵).
CONCLUSION
Our meta-analysis demonstrates that DAS28-CRP underestimates disease activity and overestimates response by the EULAR response criteria compared to DAS28-ESR.

Keyword

DAS28-CRP; DAS28-ESR; Rheumatoid arthritis

MeSH Terms

Arthritis, Rheumatoid*
Blood Sedimentation*
C-Reactive Protein*
Erythrocytes*
Humans
Rheumatic Diseases
C-Reactive Protein

Figure

• 

  Figure 1. Flow diagram of study selection process.

• 

  Figure 2. Meta-analysis of comparison between DAS28-CRP and DAS28-ESR in assessing rheumatoid arthritis activity. DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, CI: confidence interval.

• 

  Figure 3. Meta-analysis of comparison between DAS28-CRP and DAS28-ESR in determining EULAR response criteria. DAS28: disease activity score 28, CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, EULAR: European League Against Rheumatism, CI: confidence interval.

Reference

1. Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010; 376:1094–108.

2. Fransen J, van Riel PL. The disease activity score and the EULAR response criteria. Clin Exp Rheumatol. 2005; 23(5 Suppl 39):S93–9.

3. Prevoo ML, van't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995; 38:44–8.

4. Talstad I, Scheie P, Dalen H, Röli J. Influence of plasma proteins on erythrocyte morphology and sedimentation. Scand J Haematol. 1983; 31:478–84.

5. van Leeuwen MA, van Rijswijk MH, van der Heijde DM, Te Meerman GJ, van Riel PL, Houtman PM, et al. The acutephase response in relation to radiographic progression in early rheumatoid arthritis: a prospective study during the first three years of the disease. Br J Rheumatol. 1993; 32(Suppl 3):9–13.

6. Tamhane A, Redden DT, McGwin G Jr, Brown EE, Westfall AO, Reynolds RJ 4th, et al. Comparison of the disease activity score using erythrocyte sedimentation rate and C-reactive protein in African Americans with rheumatoid arthritis. J Rheumatol. 2013; 40:1812–22.

7. Castrejón I, Ortiz AM, García-Vicuña R, Lopez-Bote JP, Humbría A, Carmona L, et al. Are the C-reactive protein values and erythrocyte sedimentation rate equivalent when estimating the 28-joint disease activity score in rheumatoid arthritis? Clin Exp Rheumatol. 2008; 26:769–75.

8. Nielung L, Christensen R, Danneskiold-Samsøe B, Bliddal H, Holm CC, Ellegaard K, et al. Validity and agreement between the 28-joint disease activity score based on C-reactive protein and erythrocyte sedimentation rate in patients with rheumatoid arthritis. Arthritis. 2015; 2015; 401690.

9. Son KM, Kim SY, Lee SH, Yang CM, Seo YI, Kim HA. Comparison of the disease activity score using the erythrocyte sedimentation rate and C-reactive protein levels in Koreans with rheumatoid arthritis. Int J Rheum Dis. 2015 Jul 22; [Epub].DOI: DOI: 10.1111/1756-185X.12698.

10. Siemons L, Vonkeman HE, ten Klooster PM, van Riel PL, van de Laar MA. Interchangeability of 28-joint disease activity scores using the erythrocyte sedimentation rate or the C-reactive protein as inflammatory marker. Clin Rheumatol. 2014; 33:783–9.

11. Hensor EM, Emery P, Bingham SJ, Conaghan PG. Discrepancies in categorizing rheumatoid arthritis patients by DAS-28(ESR) and DAS-28(CRP): can they be reduced? Rheumatology (Oxford). 2010; 49:1521–9.

12. Crowson CS, Rahman MU, Matteson EL. Which measure of inflammation to use? A comparison of erythrocyte sedimentation rate and C-reactive protein measurements from randomized clinical trials of golimumab in rheumatoid arthritis. J Rheumatol. 2009; 36:1606–10.

13. Wells GA, Boers M, Li T, Tugwell PS. Investigating the validity of the minimal disease activity state for patients with rheumatoid arthritis treated with abatacept. J Rheumatol. 2009; 36:260–5.

14. Inoue E, Yamanaka H, Hara M, Tomatsu T, Kamatani N. Comparison of Disease Activity Score (DAS)28-erythrocyte sedimentation rate and DAS28-C-reactive protein threshold values. Ann Rheum Dis. 2007; 66:407–9.

15. Matsui T, Kuga Y, Kaneko A, Nishino J, Eto Y, Chiba N, et al. Disease Activity Score 28 (DAS28) using C-reactive protein underestimates disease activity and overestimates EULAR response criteria compared with DAS28 using erythrocyte sedimentation rate in a large observational cohort of rheumatoid arthritis patients in Japan. Ann Rheum Dis. 2007; 66:1221–6.

16. Sengul I, Akcay-Yalbuzdag S, Ince B, Goksel-Karatepe A, Kaya T. Comparison of the DAS28-CRP and DAS28-ESR in patients with rheumatoid arthritis. Int J Rheum Dis. 2015; 18:640–5.

17. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010; 25:603–5.

18. Davey Smith G, Egger M. Meta-analyses of randomised controlled trials. Lancet. 1997; 350:1182.

19. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986; 7:177–88.

20. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002; 21:1539–58.

21. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997; 315:629–34.

22. van der Heijde DM, van't Hof MA, van Riel PL, Theunisse LA, Lubberts EW, van Leeuwen MA, et al. Judging disease activity in clinical practice in rheumatoid arthritis: first step in the development of a disease activity score. Ann Rheum Dis. 1990; 49:916–20.

23. Prevoo ML, van't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995; 38:44–8.