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Extended report
Association with joint damage and physical functioning of nine composite indices and the 2011 ACR/EULAR remission criteria in rheumatoid arthritis
  1. N B Klarenbeek1,
  2. R Koevoets1,
  3. D M F M van der Heijde1,
  4. A H Gerards2,
  5. S ten Wolde3,
  6. P J S M Kerstens4,
  7. T W J Huizinga1,
  8. B A C Dijkmans4,5,
  9. C F Allaart1
  1. 1Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
  2. 2Department of Rheumatology, Vlietland Ziekenhuis, Schiedam, The Netherlands
  3. 3Department of Rheumatology, Kennemer Gasthuis, Haarlem, The Netherlands
  4. 4Department of Rheumatology, Jan van Breemen Research Institute, Amsterdam, The Netherlands
  5. 5Department of Rheumatology, VU Medical Centre, Amsterdam, The Netherlands
  1. Correspondence to R Koevoets, Leiden University Medical Centre, Stafcentrum reumatologie, C1-45 Postbus 9600, 2300 RC Leiden, The Netherlands; r.koevoets{at}


Objective To compare nine disease activity indices and the new American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) remission criteria in rheumatoid arthritis (RA) and to relate these to physical function and joint damage progression.

Methods Five-year data from the BeSt study were used, a randomised clinical trial comparing four treatment strategies in 508 patients with recent-onset RA. Every three months disease activity was assessed with nine indices (Disease Activity Score (DAS), DAS-C reactive proteine (DAS-CRP), Disease Activity Score in 28 joints (DAS-28), DAS28-CRP, Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and three DAS versions with adjusted tender joint scores) and categorized into remission, low, moderate and high disease activity (LDA, MDA, HDA). In addition, the recent ACR/EULAR clinical trial and practice remission was assessed 3-monthly with 28 and 68/66 joint counts. For each index, Generalized Estimating Equations analyses were performed to relate disease activity levels and the absence/presence of remission to 3-monthly assessments of physical functioning and annual radiological progression.

Results From the composite indices, CDAI and SDAI were the most stringent definitions of remission and classified more patients as LDA. DAS28 and DAS28-CRP had the highest proportions of remission and MDA and a smaller proportion of LDA. ACR/EULAR remission percentages were comparable to CDAI/SDAI: remission percentages. The variant including CRP and 68/66 joint counts was the most stringent. For all indices, higher levels of disease activity were associated with decreased physical functioning and more radiological damage progression. Despite differences in classification between the indices, no major differences in relation to the two outcomes were observed.

Conclusion The associations of nine composite indices and ACR/EULAR remission criteria with functional status and joint damage progression showed high accordance, whereas the proportions of patients classified in the disease activity levels differed.

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  • NBK and RK contributed equally to this work.

  • Funding This study was funded by a grant from the Dutch College of Health Insurances (College Voor Zorgverzekeringen) with additional funding provided by Schering-Plough B V and Centocor. The authors, not the sponsors, were responsible for the study design, trial management, data collection, data analysis and preparation of the manuscript.

  • Competing interests DMFMv/dH, TWJH, BACD and CFA received speakers' fees from various pharmaceutical companies (less than US$10000 per year).

  • Ethics approval The study was approved by the medical ethics committees of the participating hospitals and all patients gave written informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.