Evaluation of spondylarthritis activity by patients and physicians: ASDAS, BASDAI, PASS, and flares in 200 patients

Cut-Offs for Disease Activity States in Axial Spondyloarthritis With Ankylosing Spondylitis Disease Activity Score (ASDAS) Based on C-Reactive Protein and ASDAS Based on Erythrocyte Sedimentation Rate: Are They Interchangeable?

OBJECTIVE

Ankylosing Spondylitis Disease Activity Score based on C-reactive protein (ASDAS-CRP) is recommended over ASDAS based on erythrocyte sedimentation rate (ASDAS-ESR) to assess disease activity in axial spondyloarthritis (axSpA). Although ASDAS-CRP and ASDAS-ESR are not interchangeable, the same disease activity cut-offs are used for both. We aimed to estimate optimal ASDAS-ESR values corresponding to the established ASDAS-CRP cut-offs (1.3, 2.1, and 3.5) and investigate the potential improvement of level of agreement between ASDAS-ESR and ASDAS-CRP disease activity states when applying these estimated cut-offs.

METHODS

We used data from patients with axSpA from 9 European registries initiating a tumor necrosis factor inhibitor. ASDAS-ESR cut-offs were estimated using the Youden index. The level of agreement between ASDAS-ESR and ASDAS-CRP disease activity states was compared against each other.

RESULTS

In 3664 patients, mean ASDAS-CRP was higher than ASDAS-ESR at both baseline (3.6 and 3.4, respectively) and aggregated follow-up at 6, 12, or 24 months (1.9 and 1.8, respectively). The estimated ASDAS-ESR values corresponding to the established ASDAS-CRP cut-offs were 1.4, 1.9, and 3.3. By applying these cut-offs, the proportion of discordance between disease activity states according to ASDAS-ESR and ASDAS-CRP decreased from 22.93% to 19.81% in baseline data but increased from 27.17% to 28.94% in follow-up data.

CONCLUSION

We estimated the optimal ASDAS-ESR values corresponding to the established ASDAS-CRP cut-off values. However, applying the estimated cut-offs did not increase the level of agreement between ASDAS-ESR and ASDAS-CRP disease activity states to a relevant degree. Our findings did not provide evidence to reject the established cut-off values for ASDAS-ESR.

Treatment with Upadacitinib in Active Psoriatic Arthritis: Efficacy and Safety Data of the First 192 Patients from the UPJOINT Study, a Multicentre, Observational Study in Clinical Practice

INTRODUCTION

Our aim was to investigate the efficacy and safety of upadacitinib (UPA) in patients with either oligo- or polyarticular active psoriatic arthritis (PsA) using routine clinical practice data from an observational, prospective, multicentre study.

METHODS

This interim analysis contains upadacitinib efficacy and safety data from the UPJOINT study, collected from baseline to the week 24 visit with a focus on composite measures, clinical assessments and patient-reported outcomes, amongst others, including minimal disease activity (MDA), very low disease activity (VLDA), Disease Activity Index for Psoriatic Arthritis (DAPSA), Leeds Enthesitis Index (LEI), resolution of dactylitis and nail psoriasis and body surface area affected by skin psoriasis (BSA).

RESULTS

A total of 296 patients with baseline data and 192 with completed week 24 visits were included in the analysis. The proportion of patients achieving MDA increased from 2.7% at baseline to 39.1% at week 24 (95% CI 32.1, 46.3). Similarly, the number of patients in DAPSA remission (DAPSA ≤ 4) increased from 0 at baseline to 32 (16.7%) by week 24. At that time, 59.4% of the patients were either in DAPSA remission or had low disease activity (DAPSA ≤ 14). During the 24 weeks time frame, the proportion of patients with BSA ≤ 3 increased from 80.7% to 91.1%. Furthermore, at weeks 12 and 24, 45.14% and 47.19% of affected patients showed a resolution of enthesitis. Active dactylitis and nail psoriasis at baseline were reported to affect 10.5% and 22.0%, decreasing to 2.6% and 5.7% at week 24, respectively. The safety findings are consistent with the known safety profile of upadacitinib in rheumatoid arthritis and PsA; no new safety risks were identified.

CONCLUSION

The data from this study confirm the findings of previous randomized controlled trials suggesting UPA is an effective treatment for active PsA without any new safety signals in patients from daily clinical practice.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04758117.

The predictability of ASDAS on drug survival in patients with ankylosing spondylitis on biologic therapy: data from the KOBIO registry

Background

The Ankylosing Spondylitis (AS) Disease Activity Score (ASDAS) is largely used for assessing disease activity in patients with AS.

Objectives

We aimed to investigate the predictability of ASDAS on drug survival in patients with low Bath AS Disease Activity Index (BASDAI) during biologic therapy.

Design

Using data from multi-center, prospective, observational prospective cohort, Korean College of Rheumatology Biologics and Targeted Therapy (KOBIO) registry.

Methods

The study population consisted of patients enrolled in the KOBIO registry from December 2012 to December 2018. The baseline demographic data and variables such as extra-articular manifestations, HLA-B27 positivity, family history of spondyloarthritis, ASDAS C-reactive protein (CRP), BASDAI, and Bath AS Functional Index scores were collected from the database. The disease activity indices were followed yearly after initiating a tumor necrosis factor (TNF) inhibitor (TNFi). Disease activities were defined as high (ASDAS-CRP ⩾ 2.1, BASDAI ⩾ 4) and low (ASDAS-CRP < 2.1, BASDAI < 4).

Results

Data from 1773 patients were analyzed. Among 269 patients with low BASDAI at baseline, 151 (56.1%) patients had high ASDAS-CRP, yet in 142 patients with low ASDAS-CRP at baseline, only 24 (16.9%) patients had a high BASDAI. High ASDAS-CRP captured more patients who had initiated or switched to a TNFi than those with high BASDAI (92.5% versus 84.8%, respectively, p < 0.001). Moreover, among AS patients with low BASDAI after 1 year of therapy, drug persistence in the following year was significantly lower in patients with high ASDAS than in those with low ASDAS (68.7% versus 82.5%, p < 0.001).

Conclusion

ASDAS-CRP not only has its advantages over BASDAI in assessing disease activity but also low ASDAS-CRP at 1 year can be a marker of long-term drug survival of TNFi therapy.

Association of anxiety, depression and resilience with overall health and functioning in axial spondyloarthritis (axSpA): a cross-sectional study

OBJECTIVES

To evaluate the association between anxiety, depression and resilience with overall health and functioning in axial spondyloarthritis (axSpA).

DESIGN

Cross-sectional evaluation of baseline data from a prospective cohort study, with recruitment from January 2018 to March 2021.

SETTING

Outpatient clinic in a tertiary hospital in Singapore.

PARTICIPANTS

Patients aged 21 years and above who were diagnosed with axSpA.

OUTCOME MEASURES

The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depression, 10-item Connor Davidson Resilience Scale (CD-RISC-10) for resilience, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for disease activity, Bath Ankylosing Spondylitis Functional Index (BASFI) for functional limitation and Assessment of SpondyloArthritis International Society Health Index (ASAS HI) for overall health and functioning. Univariable and multivariable linear regression analyses were performed to assess the association between anxiety, depression and resilience with health and functioning.

RESULTS

We included 296 patients in this study. The median (IQR) score for HADS-Anxiety was 5.0 (2.0-8.0), with 13.5% and 13.9% having borderline abnormal and abnormal anxiety, respectively. The median (IQR) score for HADS-Depression was 3.0 (1.0-7.0), with 12.8% and 8.4% having borderline abnormal and abnormal depression, respectively. The median (IQR) CD-RISC-10 score was 29.0 (23.0-32.0) while the median (IQR) ASAS HI score was 4.0 (2.0-7.0). Apart from BASDAI, BASFI and disease duration, anxiety and depression were associated with overall health and functioning (β: 0.12, 95% CI 0.03, 0.20; β: 0.20, 95% CI 0.09, 0.31) in the multivariable linear regression. Level of resilience was not associated with health and functioning.

CONCLUSION

Anxiety and depression, but not resilience, were associated with poorer health and functioning. Clinicians could consider routinely screening for anxiety and depression in their patients, especially in patients with more severe symptoms.

The electronic medical record management systems may improve monitoring and control of disease activity in patients with ankylosing spondylitis

To investigate the impact of an electronic medical record management system (EMRMS) on disease activity and the frequency of outpatient visits among patients with ankylosing spondylitis (AS). We identified 652 patients with AS who were followed up for at least 1 year before and after the first Ankylosing Spondylitis Disease Activity Score (ASDAS) assessment and compared the number of outpatient visits and average visit time within 1 year before and after the initial ASDAS assessment. Finally, we analyzed 201 patients with AS who had complete data and received ≥ 3 continuous ASDAS assessments at an interval of 3 months, and we compared the results of the second and third ASDAS assessments with those of the first. The number of annual outpatient visits increased after ASDAS assessment (4.0 (4.0, 7.0) vs. 4.0 (4.0, 8.0), p < 0.001), particularly among those with a high initial disease activity. The average visit time was reduced within 1 year after ASDAS assessment (6.4 (8.5, 11.2) vs. 6.3 (8.3, 10.8) min, p = 0.073), especially among patients whose with an inactive disease activity was < 1.3 (ASDAS C-reactive protein (CRP) 6.7 (8.8, 11.1) vs. 6.1 (8.0, 10.3) min, p = 0.033; ASDAS erythrocyte sedimentation rate (ESR) 6.4 (8.7, 11.1) vs. 6.1 (8.1, 10.0) min, p = 0.027). Among patients who received at least three ASDAS assessments, the third ASDAS-CRP tended to be lower than the first (1.5 (0.9, 2.1) vs. 1.4 (0.8, 1.9), p = 0.058). The use of an EMRMS increased the frequency of ambulatory visits among AS patients with high and very high disease activity and reduced the visit time among those with an inactive disease. Continual ASDAS assessments may help control the disease activity of patients with AS.

Evaluating remission and low disease activity from the perspective of the patient with axial spondyloarthritis: The cross-sectional ConREspAx study

OBJECTIVES

To evaluate the properties of a single question to determine patient perception of remission and disease activity; to compare this with existing definitions for remission and low disease activity (LDA).

METHODS

Single-center, cross-sectional study in a tertiary care hospital. Patients with axSpA (fulfilling ASAS criteria) were consecutively included. Both the patient's perception of remission and LDA and that of the physician were evaluated with a single question. Agreement between the patients' perception and other current definitions was tested using the prevalence-adjusted and bias-adjusted kappa (PABAK). The sensitivity (S) and specificity (Sp) of current definitions of disease states were tested against the patient's perception as the gold standard.

RESULTS

The study population included 105 axSpA patients (63.8% males; 67.6% with radiographic sacroiliitis). Patients considered themselves to be in remission in 21% of cases and in LDA in 51.4%; physicians considered patients to be in remission in 45.7% of cases and in LDA in 35.2%. The poorest agreement was recorded for the patient's and the physician's perception of remission. The best agreement for patients' perception of remission was for a BASDAI < 2 and normal C-reactive protein values. This definition was also the most sensitive (S=72.7%) and specific (Sp=83.1%) when the patient's perception was taken as the gold standard.

CONCLUSION

In a real-life setting, the evaluation of remission by the patient through a single question was the hardest criterion to achieve, although it did prove to be a feasible, valid, and specific way to assess remission.

The association between ankylosing spondylitis and psychiatric disorders: Insights from a population based cross-sectional database

BACKGROUND

Ankylosing spondylitis (AS) is an inflammatory rheumatic disease involving the axial skeleton ultimately resulting in physical disability and psychological sequalae. The current study aims to evaluate the link between AS and psychiatric disorders, and to investigate the impact of different disease modifying drugs on such link.

METHODS

A large retrospective, population-based, cross-sectional study utilizing the Clalit-Health-Service (CHS) database was conducted on 5825 AS patients and 25,984 age- and sex-matched control individuals. The prevalence of psychiatric morbidity was compared between AS patients and age- and gender-matched controls. Predictors for psychiatric disorders in AS patients were also investigated.

RESULTS

The prevalence of psychiatric morbidity was higher in AS patients compared to controls (13.8 % vs. 9.8 %, p < 0.001). Similarly, major depression was positively associated with AS (OR 1.60, 95 % CI 1.43-1.79, p < 0.001), however, schizophrenia was negatively associated with AS (OR 0.60, 95 % CI 0.42-0.89, p < 0.011). Conventional DMARDs (cDMARDs) and anti-TNF used for management of AS were not shown to be predictors for psychiatric illnesses in AS patients.

CONCLUSIONS

Patients with AS are at a higher risk of developing psychiatric disorders, with increased risk of depression and lower risk of schizophrenia. cDMARDs and TNF-inhibitors are not predictors of psychiatric disorders in AS patients.

The BASDAI Cut-Off for Disease Activity Corresponding to the ASDAS Scores in a Taiwanese Cohort of Ankylosing Spondylitis

Objectives

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) has been widely utilized to evaluate disease activity in patients with ankylosing spondylitis (AS) by an arbitrary cut-off of ≥4 to indicate high disease activity and initiate biological therapy. The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a new composite index to assess AS disease activity states that have been defined and validated. ASDAS ≥2.1 was selected as a criterion to start biological therapy. The purpose of this study was to estimate the corresponding BASDAI and ASDAS cut-off in a Taiwanese AS cohort.

Methods

From November 2016 to October 2018, we assessed the ASDAS and the BASDAI regularly and recorded demographic data for 489 AS patients in Taichung Veterans General hospital (TCVGH) using an electronic patient-reported data system linked to electronic medical records. We used receiver operating characteristic curves with Youden's J statistic to determine the BASDAI values that correspond to ASDAS disease activity cut-offs (i.e., 1.3, 2.1, and 3.5).

Results

In our population, the best trade-off BASDAI values corresponding to ASDAS -C-reactive protein (CRP) 1.3, 2.1, and 3.5 were 2.1, 3.1, and 3.7, respectively. The optimal BASDAI values corresponding to ASDAS-erythrocyte sedimentation rates 1.3, 2.1, and 3.5 were 2.0, 2.6, and 4.8, respectively.

Conclusion

We propose a revised BASDAI cut-off based on our data, as BASDAI scores are commonly used globally. A more reasonable, lower BASDAI cut-off to initiate or change biological therapy will bring us closer to better decisions to treat AS patients.

Central sensitization has major impact on quality of life in patients with axial spondyloarthritis

INTRODUCTION

Persistent pain has large potential impact on quality of life (QoL). During the course of the disease, many patients with axial spondyloarthritis (axSpA) report persistent pain. Central sensitization (CS) may explain part of this chronic pain. However, the role of CS in relation to QoL has been sparsely studied in axSpA. Therefore, our aim was to explore the relationship between CS and QoL in patients with axSpA.

METHODS

Consecutive outpatients from the Groningen Leeuwarden axSpA (GLAS) cohort completed the Central Sensitization Inventory (CSI; range 0-100) and the AS Quality of Life (ASQoL; range 0-18). Multivariable linear regression analysis was used to explore the relationship between CSI and ASQoL scores correcting for potential confounders.

RESULTS

Of the 178 included axSpA patients, mean CSI score was 38.0 ± 14.1 and 45% scored ≥40, which indicates a high probability of CS. Mean ASQoL score was 6.0 ± 5.3 and mean ASDAS_CRP 2.1 ± 1.0. A CSI score ≥40 was significantly associated with higher ASQoL score (mean 9.7 vs. 3.3), higher ASDAS_CRP (mean 2.6 vs. 1.7), female gender (60% vs. 29%) and more often entheseal involvement (61% vs. 26%). In univariable analysis, CSI score explained a large proportion of the variation in ASQoL (B = 0.06, 95%CI: 0.05-0.07; R²=0.46). This association remained significant after correction for ASDAS_CRP, gender, entheseal involvement, comorbidities, symptom duration, smoking status, BMI class and educational level (B = 0.04, 95%CI: 0.03-0.05).

CONCLUSION

CS is strongly related to patient-reported QoL in patients with axSpA independently from other patient- and disease-related aspects.

Understanding flare in axial spondyloarthritis: novel insights from daily self-reported flare experience

OBJECTIVES

Our objective was to explore daily self-reported experiences of axial SpA (axSpA) flare based on data entered into the Project Nightingale smartphone app (www.projectnightingale.org), between 5 April 2018 and 1 April 2020.

METHODS

Paired t-tests were conducted for mean_flare_on and mean_flare_off scores for each recorded variable. The mean estimated difference between flare and non-flare values for each variable was calculated with 95% CIs. Mean, S.d. and range were reported for flare duration and frequency. Participants with ≥10 days of data entry were included for affinity propagation cluster analysis. Baseline characteristics and mean flare on vs mean flare off values were reported for each cluster. Welch's t-test was used to assess differences between clusters.

RESULTS

A total of 143/189 (75.7%) participants recorded at least one flare. Each flare lasted a mean of 4.30 days (S.d. 6.82, range 1-78), with a mean frequency of once every 35.32 days (S.d. 65.73, range 1-677). Significant relationships were identified between flare status and variable scores. Two clusters of participants were identified with distinct flare profiles. Group 1 experienced less severe worsening of symptoms during flare in comparison to group 2 (P < 0.01). However, they experienced significantly longer flare duration (7.2 vs 3.5 days; P < 0.01), perhaps indicating a prolonged, yet less intense flare experience. Groups were similar in terms of flare frequency and clinical characteristics.

CONCLUSIONS

Two clusters of participants were identified with distinct flare experiences but similar baseline clinical characteristics. Smartphone technologies capture subtle changes in disease experience not currently considered in clinical practice.

BASDAI cut-off values corresponding to ASDAS cut-off values

OBJECTIVE

To determine cut-off values of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) that can discriminate the four disease activity states (inactive disease, moderate disease activity, high disease activity, and very high disease activity), separated by the validated Ankylosing Spondylitis Disease Activity Score (ASDAS) cut-off values (1.3, 2.1, and 3.5).

METHODS

We included 333 patients with axial spondyloarthritis whose data on BASDAI and ASDAS-C reactive protein (ASDAS-CRP) were available. Receiver operating characteristic curve (ROC) analysis was performed to determine the BASDAI cut-off values that best corresponded to ASDAS-CRP cut-off values. The degree of agreement between disease activity states based on the BASDAI and ASDAS-CRP cut-off values was assessed using weighted kappa.

RESULTS

Of the total 333 patients, 52 (15.6%), 190 (57.1%), 76 (22.8%), and 15 (4.5%) patients had inactive disease, moderate disease activity, high disease activity, and very high disease activity, respectively, according to the ASDAS-CRP. ROC analyses revealed that the BASDAI values 1.9 (area under the curve [AUC]: 0.948 [0.922-0.974]), 3.5 (AUC: 0.926 [0.887-0.966]), and 4.9 (AUC: 0.917 [0.837-0.996]) best corresponded to the ASDAS-CRP values 1.3, 2.1, and 3.5, respectively. The degree of agreement between disease activity states based on the BASDAI and ASDAS-CRP cut-off values was good (weighted kappa: 0.724, p< 0.001).

CONCLUSION

The BASDAI values 1.9, 3.5, and 4.9 corresponded to the ASDAS-CRP values 1.3, 2.1, and 3.5, respectively. These cut-off values could be useful in clinical studies and real-world practice for determining disease activity status when ASDAS-CRP is unavailable.

The Importance of Outcome Measures in the Management of Inflammatory Rheumatic Diseases

Rheumatic inflammatory diseases include a diverse and heterogeneous group of multifaceted disorders in which clinical history and physical examination are essential to make treatment choices and for optimizing outcomes. Composite outcome measures have become very relevant in rheumatology to evaluate disease activity as they capture the most important dimensions of the disease into one single measure. Most outcome measures may include disease manifestations, laboratory data, physician examination as well as the patient perspective as different outcome dimensions of the disease into a simple index. These outcome measures have proved their utility for guiding treatment in treat-to- target strategies and personalized medicine, with remission being the ultimate goal. In this narrative review, we go over the most commonly used outcome measures in rheumatoid arthritis, spondyloarthropathies, including psoriatic arthritis, and systemic lupus erythematosus to provide a practical summary for clinicians for everyday routine care.

Gender differences in factors associated with low quality of life and depression in Korean patients with ankylosing spondylitis

PURPOSE

To identify predictors of low health-related quality of life (HRQoL) and depression in ankylosing spondylitis (AS) patients with a focus on gender differences.

METHODS

We conducted a cross-sectional cohort study. Both AS-related clinical data and contextual factors were obtained. HRQoL and depressive mood were assessed by EuroQol-5 dimension (EQ-5D) and the Center for Epidemiological Studies Depression Scale (CES-D), respectively. Gender-stratified multivariable logistic regression analyses were performed.

RESULTS

Among 211 patients, 161 were males. Males had similar disease activity and higher radiographic damage compared with females. There was no significant difference in EQ-5D index score between genders. CES-D score was higher in females. Higher ASDAS-C-reactive protein (CRP) was associated with low HRQoL in both males (Odds ratio [OR] 4.25, 95% confidence interval [CI] 2.42-7.46) and females (OR 2.94, 95% CI 1.02-8.48). Being employed was associated with decreased possibility of having low HRQoL in males (OR 0.39, 95% CI 0.16-0.95). Regarding depression, higher ASDAS-CRP (OR 1.87, 95% CI 1.03-3.40), current smoking (OR 2.98, 95% CI 1.09-8.15), and being employed (OR 0.17, 95% CI 0.06-0.46) were associated with depression in males. For females, living with a partner was related to depression (OR 0.08, 95% CI 0.01-0.93).

CONCLUSION

AS patients with high disease activity are likely to be suffering from low HRQoL. Both disease-related factors and contextual factors were associated with depression, and predictors showed some differences between genders. Awareness of gender differences in comprehensive assessment can lead us to better personalized management in AS patients.

The relationship between patient acceptable symptom state and disease activity in patients with psoriatic arthritis

OBJECTIVES

The Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA) are composite PsA disease activity measures. We sought to identify the PASDAS and DAPSA cut-off points consistent with patient acceptable symptom state (PASS), the threshold of symptoms beyond which patients consider themselves well, and examine PASS across published PASDAS and DAPSA thresholds for low, moderate and high disease activity.

METHODS

We used a standard protocol including physician assessment and patient-reported outcomes to prospectively record measures required to calculate PASDAS and DAPSA. We identified PASS thresholds for the PASDAS and DAPSA using receiver operating characteristics curve analyses. We assessed the frequency of reporting acceptable symptom state across disease activity thresholds for PASDAS and DAPSA scores.

RESULTS

A total of 229 patients (58.5% male, mean age 55.5 years, mean disease duration 17.1 years) were recruited. The PASS threshold for the PASDAS was 3.79 [area under the curve (AUC) 0.86, sensitivity 0.75, specificity 0.82] and for the DAPSA was 11.10 (AUC 0.91, sensitivity 0.89, specificity 0.82). With the PASDAS, 90% of patients defined as having low disease activity considered their symptom state acceptable, compared with 55% and 17% among those with moderate and high disease activity, respectively. With the DAPSA, 98% of patients in disease remission considered their symptom state acceptable compared with 85, 22 and 18% among those with low, moderate and high disease activity, respectively.

CONCLUSION

We have defined PASS thresholds for PASDAS and DAPSA. The PASDAS target for low disease activity and DAPSA targets of low disease activity or remission align well with PASS.

Detection of Flares by Decrease in Physical Activity, Collected Using Wearable Activity Trackers in Rheumatoid Arthritis or Axial Spondyloarthritis: An Application of Machine Learning Analyses in Rheumatology

OBJECTIVE

Flares in rheumatoid arthritis (RA) and axial spondyloarthritis (SpA) may influence physical activity. The aim of this study was to assess longitudinally the association between patient-reported flares and activity-tracker-provided steps per minute, using machine learning.

METHODS

This prospective observational study (ActConnect) included patients with definite RA or axial SpA. For a 3-month time period, physical activity was assessed continuously by number of steps/minute, using a consumer grade activity tracker, and flares were self-assessed weekly. Machine-learning techniques were applied to the data set. After intrapatient normalization of the physical activity data, multiclass Bayesian methods were used to calculate sensitivities, specificities, and predictive values of the machine-generated models of physical activity in order to predict patient-reported flares.

RESULTS

Overall, 155 patients (1,339 weekly flare assessments and 224,952 hours of physical activity assessments) were analyzed. The mean ± SD age for patients with RA (n = 82) was 48.9 ± 12.6 years and was 41.2 ± 10.3 years for those with axial SpA (n = 73). The mean ± SD disease duration was 10.5 ± 8.8 years for patients with RA and 10.8 ± 9.1 years for those with axial SpA. Fourteen patients with RA (17.1%) and 41 patients with axial SpA (56.2%) were male. Disease was well-controlled (Disease Activity Score in 28 joints mean ± SD 2.2 ± 1.2; Bath Ankylosing Spondylitis Disease Activity Index score mean ± SD 3.1 ± 2.0), but flares were frequent (22.7% of all weekly assessments). The model generated by machine learning performed well against patient-reported flares (mean sensitivity 96% [95% confidence interval (95% CI) 94-97%], mean specificity 97% [95% CI 96-97%], mean positive predictive value 91% [95% CI 88-96%], and negative predictive value 99% [95% CI 98-100%]). Sensitivity analyses were confirmatory.

CONCLUSION

Although these pilot findings will have to be confirmed, the correct detection of flares by machine-learning processing of activity tracker data provides a framework for future studies of remote-control monitoring of disease activity, with great precision and minimal patient burden.

Relationship Between Health-Related Quality of Life and Patient Acceptable Symptom State With Disease Activity and Functional Status in Patients With Ankylosing Spondylitis in Thailand

OBJECTIVE

This study aimed to identify factors associated with EuroQoL-5 Dimensions, 5 Levels and Patient Acceptable Symptom State (PASS) and health utility (HU) in Thai patients with ankylosing spondylitis (AS).

METHODS

This was a cross-sectional study of consecutive AS patients visiting Siriraj Hospital between May 31, 2012, and March 31, 2016. Demographic data and outcomes related to HU (Thai version of EuroQoL-5 Dimensions, 5 Levels), disease activity (Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score-erythrocyte sedimentation rate or Ankylosing Spondylitis Disease Activity Score-C-reactive protein, number of tender and swollen joints, and enthesitis), and functional status (Bath Ankylosing Spondylitis Functional Index and Health Assessment Questionnaire) were collected. Regression analysis was used to explore factors associated with each EuroQOL-5 Dimensions (EQ-5D) domain, HU, and PASS.

RESULTS

Among 119 AS patients, the mean age was 40.4 years; 61.3% were male. The mean EQ-5D was 0.75. In univariate analysis, lower disease activity and less impaired function were significantly associated with higher HU and not to mild problems in each EQ-5D domain. In multivariate regression analysis, Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein, and Health Assessment Questionnaire adjusting for age explained 77.4% of the HU variance. Patients answering yes to PASS were significantly older, had higher HU, and lower disease activity compared with those answering no to PASS. Usual activity and pain problems were importantly related to PASS after adjusting for other domains and age.

CONCLUSIONS

Disease activity and functional status in AS patients were significant factors related to HU and PASS. To improve quality of life, treatment goals should be achieving remission, improving function, and controlling pain.

Depression in ankylosing spondylitis and the role of disease-related and contextual factors: a cross-sectional study

BACKGROUND

Patients with ankylosing spondylitis (AS) have a higher prevalence of depression compared to the general population. Comorbid depression in AS likely has a multifactorial origin. While several disease-related and contextual factors have been associated with depressive symptoms in AS, a comprehensive model of their interrelations is currently lacking. Such a model could help understand the mechanisms leading to, or maintaining, depression in AS. The objectives of the current study were to determine which factors are associated with depressive symptoms in AS and to understand their underlying relationships.

METHODS

Data from a cross-sectional survey-based multicentre study were used. Potential determinants included both contextual and disease-related factors. Depressive symptoms were assessed by the Hospital Anxiety and Depression Subscale (HADS-D). Direct and indirect associations between risk factors and the latent depressive symptom outcome were explored using structural equation modelling. A final model was selected based on model fit criteria and clinical plausibility.

RESULTS

Among 245 patients, median HADS-D score was 3 (interquartile range 1-6), and 44 patients (18%) had a HADS-D score ≥ 8, indicating possible depression. In the final model, contextual factors significantly associated with depressive symptoms were male gender, being employed, lower income, lower mastery and worse satisfaction with social role participation. Bath AS Disease Activity Index (BASDAI) was the only disease-related factor that was associated with depressive symptoms, acted only indirectly via mastery, and its standardized total effect on depressive symptoms was smaller than that of several contextual factors. Mastery had a central role in the path diagram and mediated the effects of BASDAI, income and satisfaction with social role participation on depressive symptoms. The final model explained 64% of the variance in the depression outcome.

CONCLUSIONS

Both contextual and disease-related factors are associated with depressive symptoms in AS. Mastery, the extent to which one feels in control over life and disease, has a key role in this process. Results support a relevance of self-efficacy in disease management and patient education. In order to improve patients' mental health, research is warranted whether mastery and its relation with depression can be modified.

Treat to Target in Axial Spondyloarthritis: What Are the Issues?

PURPOSE OF THE REVIEW

Treat to Target (T2T) strategy has been widely used in the management of chronic medical conditions, such as hypertension, diabetes, and hypothyroidism, as well as rheumatic diseases, such as rheumatoid arthritis and gout. The purpose of this review is to discuss the importance, feasibility, and challenges in adopting the T2T strategy for the management of axial spondyloarthritis (axSpA).

RECENT FINDINGS

In 2014, a panel of international experts published recommendations for T2T in axSpA. Recent Tight Control of Inflammation in Early Psoriatic Arthritis (TICOPA) trial demonstrated efficacy of T2T in the management of the psoriatic arthritis. However, there are several issues in the adoption of T2T in axSpA. They include lack of evidence of the impact of aggressive management on clinical and radiographic outcomes in axSpA and unavailability of a definite target for the treatment, as well as limited therapeutic options. In this review, we discuss the intricacies of the T2T strategy in axSpA. We need more clinical evidence in the form of randomized clinical studies to assess the impact of T2T on outcomes in axSpA. We also need a definite target which is useful in the routine clinical practice, as well as for clinical trials.

Prevalence of Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease in a cohort of patients treated with TNF-alpha inhibitors

BACKGROUND

Treat to target (T2T), aiming at inactive disease (ID), has become the recommended strategy for axial-SpA (ax-SpA). Using the Ankylosing Spondylitis Disease Activity Score (ASDAS), we assessed the prevalence of ID in ax-SpA patients treated with TNFα inhibitors (TNFi).

METHODS

A multicentric, cross-sectional study was performed assessing disease activity status (BASDAI and ASDAS) of consecutive patients with ax-SpA on stable treatment with TNFi for at least six months. We analyzed differences with nonradiographic axSpA (nr-ax-SpA) and the influence of population characteristics and comorbidities in reaching ID. ID was defined as ASDAS-CRP <1.3.

RESULTS

A total of 218 patients were enrolled, 165 with AS and 53 with nr-ax-SpA. ASDAS-CRP ID was reached by 89 (40.8%) patients, while 163 (74.8%) of patients achieved good disease control with BASDAI. There were no significant differences between the two diagnostic groups. Multivariate logistic regression demonstrated a negative correlation of concomitant fibromyalgia, higher BASMI and current NSAIDs with the chances of reaching ASDAS-CRP ID or BASDAI <4.

CONCLUSION

T2T represents a new challenge in the management of ax-SpA, with recently introduced disease activity measures being significantly more stringent. The prevalence of ID was affected by concomitant fibromyalgia, decreased spine mobility and concomitant NSAIDs.

Flares assessed weekly in patients with rheumatoid arthritis or axial spondyloarthritis and relationship with physical activity measured using a connected activity tracker: a 3-month study

BACKGROUND

The evolution of rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) is marked by flares, although their frequency is unclear. Flares may impact physical activity. Activity can be assessed objectively using activity trackers. The objective was to assess longitudinally the frequency of flares and the association between flares and objective physical activity.

METHODS

This prospective observational study (ActConnect) included patients with definite clinician-confirmed RA or axSpA, owning a smartphone. During 3 months, physical activity was assessed continuously by number of steps/day, using an activity tracker, and disease flares were self-assessed weekly using a specific flare question and, if relevant, the duration of the flare. The relationship between flares and physical activity for each week (time point) was assessed by linear mixed models.

RESULTS

In all, 170/178 patients (91 patients with RA and 79 patients with axSpA; 1553 time points) were analysed: mean age was 45.5±12.4 years, mean disease duration was 10.3±8.7 years, 60 (35.3%) were men and 90 (52.9%) received biologics. The disease was well-controlled (mean Disease Activity Score 28: 2.3±1.2; mean Bath Ankylosing Spondylitis Disease Activity Index score: 3.3±2.1). Patients self-reported flares in 28.2%±28.1% of the weekly assessments. Most flares (78.9%±31.4%) lasted ≤3 days. Persistent flares lasting more than 3 days were independently associated with less weekly physical activity (p=0.03), leading to a relative decrease of 12%-21% and an absolute decrease ranging from 836 to 1462 steps/day.

CONCLUSION

Flares were frequent but usually of short duration in these stable patients with RA and axSpA. Persistent flares were related to a moderate decrease in physical activity, confirming objectively the functional impact of patient-reported flares.

Gene Expression Analysis before and after Treatment with Adalimumab in Patients with Ankylosing Spondylitis Identifies Molecular Pathways Associated with Response to Therapy

The etiology of Ankylosing spondylitis (AS) is still unknown and the identification of the involved molecular pathogenetic pathways is a current challenge in the study of the disease. Adalimumab (ADA), an anti-tumor necrosis factor (TNF)-alpha agent, is used in the treatment of AS. We aimed at identifying pathogenetic pathways modified by ADA in patients with a good response to the treatment. Gene expression analysis of Peripheral Blood Cells (PBC) from six responders and four not responder patients was performed before and after treatment. Differentially expressed genes (DEGs) were submitted to functional enrichment analysis and network analysis, followed by modules selection. Most of the DEGs were involved in signaling pathways and in immune response. We identified three modules that were mostly impacted by ADA therapy and included genes involved in mitogen activated protein (MAP) kinase, wingless related integration site (Wnt), fibroblast growth factor (FGF) receptor, and Toll-like receptor (TCR) signaling. A separate analysis showed that a higher percentage of DEGs was modified by ADA in responders (44%) compared to non-responders (12%). Moreover, only in the responder group, TNF, Wnt, TLRs and type I interferon signaling were corrected by the treatment. We hypothesize that these pathways are strongly associated to AS pathogenesis and that they might be considered as possible targets of new drugs in the treatment of AS.

Plasma levels of pentraxin 3 in patients with spondyloarthritis

CONTEXT

Determining the disease's inflammatory activity in spondyloarthritis (SpA) is difficult although very important as it is this that drives treatment.

OBJECTIVE

To investigate if plasma pentraxin-3 (PTX3) could act as an inflammatory marker in SpA.

METHODS

Eighty one SpA patients (11 with psoriatic arthritis (PsoA) and 70 with ankylosing spondylitis (AS)) and 90 gender and age paired controls were studied for plasma PTX3 levels by ELISA. Patients had determinations of disease activity through C reactive protein (CRP), erythrocyte sedimentation rate (ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP. Epidemiological, clinical and treatment data were collected through chart review.

RESULTS

SpA patients had lower concentrations of plasma PTX3 than controls (median of 0.95 ng/mL vs 1.64 ng/mL; p < 0.0001). Correlation of PTX3 levels and BASDAI, ASDAS-CPR, CRP levels and ESR could not be found. No differences in PTX3 levels were detected between PSoA and AS patients (p = 0.42). Uveitis, presence of HLA B27, tobacco exposure, age and disease duration did not influence PTX3 levels.

CONCLUSIONS

PTX3 plasma levels do not reflect disease activity in SpA. However, it probably participates in the ethiopathogenetic process, as it is consumed in these patients.

Patient-reported Flares in Ankylosing Spondylitis: A Cross-sectional Analysis of 234 Patients

OBJECTIVE

Ankylosing spondylitis (AS) is characterized by periodic flares. The objective of this study was to assess the frequency of patient-reported flares and their related factors.

METHODS

This cross-sectional study analyzed the 2004 data of a Canadian cohort. Participants had AS according to the modified New York criteria. Current flare status ("Are you experiencing a current flare"?), number of flares over the past 3 months, their average duration, the Bath Ankylosing Spondylitis Disease Activity and Functional Index (BASDAI and BASFI, respectively), and the AS Quality of Life questionnaire were assessed by self-report. Univariate and multivariate regressions analyzed the factors associated with current flare.

RESULTS

Among 234 analyzed patients, 169 (73.5%) were men, mean age was 45.5 (± 11.8) years, mean disease duration of 21.7 (± 11.7) years, and mean BASDAI and BASFI (0-10) of 4.4 (± 2.3) and 3.4 (± 2.6), respectively; 18 (7.7%) received antitumor necrosis factor (anti-TNF). Overall, 175 patients (74.8%) reported flares and 117 (50%) were currently in flare. Patients reporting flares had a median of 3 flares in 3 months, with a median duration of 2 weeks. Overall, the 234 patients spent a median of 25% of their time in flare. In multivariate analyses, current flare was significantly associated with higher BASDAI (OR 2.01, p = 0.01), worse quality of life (OR 1.37, p = 0.004), shorter AS duration (OR 1.19, p = 0.04), and less anti-TNF (OR 7.14, p = 0.03).

CONCLUSION

In this population, before the wide use of biologics, flares were frequent and long. As expected, flare was associated with higher disease activity, suggesting the validity of the concept of patient-reported flares.

Responsiveness of a simple RAPID-3-like index compared to disease-specific BASDAI and ASDAS indices in patients with axial spondyloarthritis

Objective

To evaluate the responsiveness of a simple routine assessment of patient index data (RAPID3)-like index that includes only 3 patient self-report measures (physical function, pain and patient global estimate) compared to that of traditional composite indices to assess change in patients with axial spondyloarthritis (Ax-SpA).

Methods

Devenir des Spondylarthropathies Indifférenciées Récentes (DESIR) is a prospective cohort of patients with inflammatory back pain suggestive of Ax-SpA. The study included 461 patients, who met the Assessment of SpondyloArthritis International Society (ASAS) classification criteria for Ax-SpA. A simple RAPID3-like index was compared with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the AS Disease Activity Score (ASDAS) scores for responsiveness over 6 months. Construct validity was also evaluated through Pearson correlations and discrimination of disease activity through standardised mean differences for the 3 indices.

Results

The RAPID3-like index was correlated significantly with BASDAI (r=0.84, p<0.005) and ASDAS-C-reactive protein (CRP) (r=0.74, p<0.005), similar to correlations of BASDAI with ASDAS-CRP (r=0.76, p<0.005). The percentage of patients with inactive disease ranged from 9% to 25% and with high activity from 10% to 45%, according to various measures. The capacity to discriminate between high and low disease activity was similar for the 3 indices. The strength of agreement of RAPID3 with ASDAS-CRP was moderate (0.44) and lower with BASDAI (0.37). Responsiveness over 6 months was slightly higher for ASDAS-CRP and the RAPID3-like index than that for BASDAI.

Conclusions

The RAPID3-like index provides similar information to BASDAI and ASDAS-CRP concerning responsiveness over 6 months. RAPID3 appears feasible to assess patients with Ax-SpA quantitatively over time in busy clinical settings.

Is there any gender-specific difference in the cut-off values of ankylosing spondylitis disease activity score in patients with axial spondyloarthritis?

AIM

To assess the validity of Assessment in Spondyloarthritis International Society (ASAS) endorsed Ankylosing Spondylitis Disease Activity Score (ASDAS) C-reactive protein (-CRP) and ASDAS erythrocyte sedimentation rate (-ESR) in axial spondyloarthritis (axSpA) and to estimate the cut-off values for male and female patients with axSpA.

METHODS

Patients with axSpA were assessed for disease activity, functions, mobility and AS Quality of Life (ASQoL) and pain. The discriminant ability of ASDAS versions was assessed using standardized mean differences. Optimal cut-off values of ASDAS versions were calculated.

RESULTS

Patients with axSpA were included (196 AS, 164 non-radiographic axSpA). ASDAS versions and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) had good correlations with patient's global (PtG) and physician's global (PhG) assessment in both groups; however, men had relatively higher coefficients. Women had significantly higher pain, ASQoL, ASDAS-ESR, BASDAI item scores, PtG, PhG and ESR. Discriminant abilities of ASDAS-CRP, ASDAS-ESR and BASDAI were similar in men and women regarding low and high disease activity. ASDAS cut-offs are quite similar in both genders and in accordance with predefined values. The cut-offs for ASDAS-ESR were relatively lower than ASDAS-CRP and women tend to have higher cut-offs than men.

CONCLUSION

The construct validity of ASDAS-CRP to discriminate low and high disease activity and cut-off values are similar in male and female patients with axSpA; however, cut-offs for ASDAS-ESR need to be defined.

Predictors of Loss of Remission and Disease Flares in Patients with Axial Spondyloarthritis Receiving Antitumor Necrosis Factor Treatment: A Retrospective Study

Objective.

The aim of this study was to evaluate rate and predictive factors of loss of remission and disease flare in patients with axial spondyloarthritis (axSpA) receiving antitumor necrosis factor (anti-TNF) treatment.

Methods.

In this retrospective multicenter study, patients with axSpA, according to the Assessment of Spondyloarthritis international Society (ASAS) criteria, treated with adalimumab, etanercept, or infliximab with a minimum followup of 12 months and satisfying the ASAS partial remission criteria and/or Ankylosing Spondylitis Disease Activity Score (ASDAS) inactive disease were studied. Disease flare was defined as a Bath Ankylosing Spondylitis Disease Activity Index score > 4.5 or ASDAS score > 2.5 on at least 1 occasion.

Results.

One hundred seventy-four patients with axSpA were studied. After a median [interquartile range (IQR)] followup of 4 years (2–6), 37 patients (21.2%) experienced a loss of remission and 28 (16.1% of the whole study group) a disease flare. Median (IQR) duration of remission in patients who lost this status was 1 year (0.625–2). Higher median erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, continuous nonsteroidal antiinflammatory drug (NSAID) use, and an ASDAS-CRP ≥ 0.8 during the remission period were significantly associated with both loss of remission and disease flare. At the multivariate analysis, continuous NSAID intake (OR 4.05, 95% CI 1.4–11.74, p = 0.010) and ESR > 15 (OR 2.90, 95% CI 1.23–6.82, p = 0.015) were the only factors predictive of disease reactivation.

Conclusion.

In this study, loss of remission and disease flares occurred, respectively, in about 21% and 16% of the patients with axSpA who achieved a state of remission while receiving anti-TNF therapy. Residual disease activity was associated with disease reactivation.

Risk of Psychiatric Disorders following Ankylosing Spondylitis: A Nationwide Population-based Retrospective Cohort Study

OBJECTIVE

Ankylosing spondylitis (AS) is a common inflammatory rheumatic disease. A higher prevalence of psychiatric comorbidities, including depressive disorder, has been proven in patients with AS. However, a clear temporal causal relationship between AS and psychiatric disorders has not been well established. We performed a nationwide population-based retrospective cohort study to analyze the relationship between AS and the subsequent development of psychiatric disorders, including schizophrenia, bipolar disorder, depressive disorders, anxiety disorders, and sleep disorders.

METHODS

We identified subjects who were newly diagnosed with AS between January 1, 2000, and December 31, 2008, in the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed of patients without AS who were matched according to age and sex. All patients with AS and control patients were observed until diagnosed with psychiatric disorders, or until death or withdrawal from the NHI system, or until December 31, 2009.

RESULTS

The AS cohort consisted of 2331 patients and the comparison cohort consisted of 9324 matched control patients without AS. The adjusted HR for depressive disorders, anxiety disorders, and sleep disorders in subjects with AS were higher than those of the controls during followup (HR 1.718, 95% CI 1.303-2.265; HR 1.848, 95% CI 1.369-2.494; and HR 1.494, 95% CI 1.031-2.162, respectively).

CONCLUSION

AS might increase the risk of a subsequent newly diagnosed depressive disorder, anxiety disorder, or sleep disorder, but not schizophrenia or bipolar disorder. These observations highlight the need for psychiatric evaluation and intervention for patients with AS.

Performance characteristics of the simplified version of ankylosing spondylitis disease activity score (SASDAS)

Various types of disease activity measures are available for axial spondyloarthritis (axSpA), and there is no gold standard for all individual patients. The ankylosing spondylitis disease activity score (ASDAS) is highly discriminatory, sensitive to change, and associated with structural progression. A simplified version of the ASDAS (SASDAS) was proposed and found to be a simple and practical tool to assess disease activity. Our aim was to test the performance characteristics of the SASDAS and compare it with validated tools. In total, 97 consecutive ankylosing spondylitis (AS) patients were included in the study. Disease activity was assessed by the ASDAS-erythrocyte sedimentation rate (ESR), ASDAS-C-reactive protein (CRP), bath ankylosing spondylitis disease activity index (BASDAI), and SASDAS. The relationship among these activity indices and the level of agreement of various activity categories were tested. There was a strong correlation between the SASDAS and other activity indices, including the BASDAI (r = 0.916, p < 0.001), ASDAS-CRP (r = 0.847, p < 0.001), and ASDAS-ESR (r = 0.942, p < 0.001). Although the agreement between the ASDAS-ESR and SASDAS was good (weighted kappa of 0.744 and total agreement of 77 %), there was moderate agreement between the ASDAS-CRP and SASDAS (weighted kappa of 0.579 and total agreement of 66 %). The disagreement was particularly striking in "moderate" and "high disease activity" states. Approximately 40 % of patients classified as moderate activity according to the ASDAS-ESR and 45 % according to the ASDAS-CRP were differentially categorized by the SASDAS. The results of the present analysis suggest that the simplified version of the ASDAS-ESR should be further validated in various settings and populations due to a questionable level of agreement between the ASDAS-CRP and SASDAS.

Predictors of response and drug survival in ankylosing spondylitis patients treated with infliximab

Background

The advent of anti-tumor necrosis factor-α (TNFα) drugs has changed the course of ankylosing spondylitis (AS). While data are available concerning the long term effectiveness of single anti-TNF agents, little has been published about predictors of treatment response in AS. The aim of this retrospective study was to evaluate the survival, effectiveness, and safety of infliximab over a 5-year period and to identify predictors of disease outcome.

Methods

Seventy AS patients attending the Rheumatology Clinic of the University of Padua who were treated with intravenous infliximab at 0, 2, 4 weeks and then every 6, 8, or up to 16 weeks were studied retrospectively. Demographic information, laboratory inflammatory and disease indices (BASDAI, BASFI, BASMI) were collected (at baseline, 3, 6, 12 months and once a year thereafter). Clinical improvement, drug tolerability, adverse events/side effects and causes leading to discontinuation were recorded.

Results

Infliximab caused a rapid, persistent improvement at all the assessment times in the BASDAI 50 (71.4 %) and ASDAS scores (97.1 % in ASAS20, 80 % in ASAS40, 80 % in ASAS5/6), and already within 6 months of beginning treatment in 50 % percent of the patients. The other 50 % withdrew because of: adverse events (12 = 34.3 %), side effects (5 = 14.3 %), drug inefficacy (12 = 34.3 %), spontaneously (4 = 11.4 %). Those who did not respond were prevalently females (34.3 % vs 17.1 %).

Conclusion

Factors such as female sex, use of steroids, persistently high inflammatory levels, BASFI and BASDAI indices were found to be negative predictors of treatment response. Infliximab was found to be safe, effective and well-tolerated; it elicited satisfactory long term response and drug survival rates.

Patient Acceptable Symptom State in Self-Report Questionnaires and Composite Clinical Disease Index for Assessing Rheumatoid Arthritis Activity: Identification of Cut-Off Points for Routine Care

OBJECTIVE

To provide information on the value of Patient Acceptable Symptom State (PASS) in rheumatoid arthritis (RA) by the identification of PASS thresholds for patient-reported outcomes (PROs) composite scores.

METHODS

The characteristics of RA patients with affirmative and negative assignment to PASS were compared. Contributors to physician response were estimated by logistic regression models and PASS thresholds by the 75th percentile and receiver-operating characteristic (ROC) curve methods.

RESULTS

303 RA patients completed the study. All PROs were different between the PASS (+) and PASS (-) groups (p < 0.0001). The thresholds with the 75th percentile approach were 2.0 for the RA Impact of Disease (RAID) score, 2.5 for the PRO-CLinical ARthritis Activity (PRO-CLARA) index, and 1.0 for the Recent-Onset Arthritis Disability (ROAD) questionnaire. The cut-off values for Clinical Disease Activity Index (CDAI) were in the moderate range of disease activity. Assessing the size of the logistic regression coefficients, the strongest predictors of PASS were the disease activity (p = 0.0007) and functional state level (0.006).

CONCLUSION

PASS thresholds were relatively high and many patients in PASS had moderate disease activity states according to CDAI. Factors such as disease activity and physical function may influence a negative PASS.