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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
  1. Toshihiro Matsui1,9,
  2. Yoshiaki Kuga2,*,9,
  3. Atsushi Kaneko3,9,
  4. Jinju Nishino4,9,
  5. Yoshito Eto3,9,
  6. Noriyuki Chiba5,9,
  7. Masayuki Yasuda6,9,
  8. Koichiro Saisho7,9,
  9. Kota Shimada8,9,
  10. Shigeto Tohma8,9
  1. 1Department of Rheumatology, Sagamihara National Hospital, National Hospital Organization (NHO), Kanagawa, Japan
  2. 2Division of Rheumatic Diseases, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
  3. 3Department of Orthopedics, Nagoya Medical Center, NHO, Nagoya, Japan
  4. 4Nishino Orthopedics Clinic, Tokyo, Japan
  5. 5Department of Rheumatology, Morioka National Hospital, NHO, Iwate, Japan
  6. 6Department of Rheumatology, Beppu Medical Center, NHO, Oita, Japan
  7. 7Department of Rheumatology, Miyakonojo Hospital, NHO, Miyazaki, Japan
  8. 8Division of Rheumatology, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, NHO, Kanagawa, Japan
  9. 9iR-net (Division of Rheumatology, Immunological Disorder Network, National Hospital Organization, Japan)
  1. Correspondence to:
    Dr Toshihiro Matsui
    Department of Rheumatology, Sagamihara National Hospital, National Hospital Organization 18-1, Sakuradai Sagamihara-city, Kanagawa, 228-8522, Japan; t-matsui{at}


Objectives: To compare disease activity and the improvement of disease activity evaluated between by Disease Activity Score 28 using erythrocyte sedimentation rate (DAS28-ESR) and by DAS28 using C-reactive protein (DAS28-CRP) in Japanese patients with rheumatoid arthritis (RA).

Methods: Data from 3073 RA patients registered in the large cohort database (NinJa: National Database of Rheumatic Diseases by iR-net in Japan) of 2003 was used to calculate DAS28-ESR and DAS28-CRP and disease activities were evaluated. Improvements in disease activities were also evaluated according to the European League Against Rheumatism (EULAR) response criteria in 1482 RA patients whose DAS28-ESR and DAS28-CRP could be calculated from data for both 2002 and 2003.

Results: The mean value of DAS28-CRP (3.59, SD 1.25) was significantly smaller than that of mean DAS28-ESR (4.31, SD 1.32) (p < 0.0001). The number of patients who satisfied the criteria of remission was 297 (9.7%) in DAS28-ESR versus 705 (22.9%) in DAS28-CRP and the number of patients with high disease activity was 842 (27.4%) versus 357 (11.6%) for DAS28-ESR and DAS28-CRP, respectively; there was a significant difference between the two (p < 0.0001). Change of respective DAS28 was significantly correlated (ΔDAS28-ESR −0.05, SD 1.14 versus ΔDAS28-CRP −0.10, SD 1.10) (p < 0.0001); however, the number of “good response” patients was significantly different (p < 0.03) between DAS28-ESR (97 patients, 6.5%) and DAS28-CRP (136 patients, 9.2%).

Conclusions: DAS28-CRP significantly underestimated disease activity and overestimated the improvement in disease activity compared with DAS28-ESR. DAS28-CRP should be evaluated using different criteria from that for DAS28-ESR.

  • CRP, C-reactive protein
  • DAS28, Disease Activity Score 28
  • ESR,
  • erythrocyte sedimentation rate,
  • mHAQ, modified health assessment questionnaire
  • RA, rheumatoid arthritis
  • VAS, visual analogue scale

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  • * Present address: Department of Orthopedic Surgery, Ogawa Red Cross Hospital, Saitama, Japan.

  • Sources of support: This work was supported in part by grants from the Ministry of Health, Labour and Welfare, Japan.