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Definition of treatment response in rheumatoid arthritis based on the simplified and the clinical disease activity index
  1. Daniel Aletaha1,
  2. Jose Martinez-Avila1,
  3. Tore K Kvien2,
  4. Josef S Smolen1,3
  1. 1Division of Rheumatology, Medical University of Vienna, Vienna, Austria
  2. 2Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  3. 3Second Department of Medicine, Hietzing Hospital, Vienna, Austria
  1. Correspondence to Dr Daniel Aletaha, Medical University of Vienna, Department of Rheumatology, Spitalgasse 23, 1090 Vienna, Austria; daniel.aletaha{at}


Background The simplified disease activity index (SDAI) and the clinical disease activity index (CDAI) are established instruments to measure disease activity in rheumatoid arthritis (RA). To date, no validated response definitions for the SDAI and CDAI are available.

Objective The authors aimed to define minor, moderate and major response criteria for the SDAI.

Methods The authors used data from two clinical trials on infliximab versus methotrexate in early (ASPIRE) or established (ATTRACT) RA, and identified the three SDAI cutpoints based on the best agreement (by κ statistics) with the American College of Rheumatology (ACR)20/50/70 responses. Cutpoints were then tested for different aspects of validity in the trial datasets and in a Norwegian disease modifying antirheumatic drug prescription dataset (NOR-DMARD).

Results Based on agreement with the ACR response, the minor, moderate and major responses were identified as SDAI 50%, 70% and 85% improvement. These cutpoints had good face validity concerning the disease activity states achieved by the different response definitions. Construct validity was shown by a clear association of increasing SDAI response categories with increasing levels of functional improvement, achievement of better functional states and lower annual radiographic progression. Across SDAI 50/70/85, the sensitivities regarding a patient-perceived improvement decreased (73%/39%/22%) and the specificities increased (61%/89%/96%) in a meaningful way. Further, the cutpoints discriminated the different treatment arms in ASPIRE and ATTRACT. The same cutpoints were used for the CDAI, with similar results in the validation analyses.

Conclusion These new response criteria expand the usefulness of the SDAI and CDAI for their use as endpoints in clinical trials beyond the definition of disease activity categories.

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  • Handling editor Johannes WJ Bijlsma

  • Funding This study was supported through Coordination Theme 1 (Health) of the European Community's FP7; Grant Agreement number HEALTH-F2-2008-223404 (Masterswitch). This is a publication of the Joint and Bone Center for Diagnosis, Research and Therapy of Musculoskeletal Disorders of the Medical University of Vienna.

  • Competing interests DA was involved in the development of SDAI and CDAI, received consulting and speaking honoraria from MSD. JM-A and T KK declare no competing interests. JSS was involved in development of SDAI and CDAI and received consulting and speaking honoraria from Centocor and MSD.

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