6The Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) to monitor patients in standard clinical care
Section snippets
The triad and interrelationship of disease activity, joint damage, and functional impairment
Synovitis is the cardinal consequence of the pathogenetic events of inflammatory joint diseases. The type of synovitis encountered by patients with rheumatoid arthritis (RA) contrasts that of other arthritides by its high propensity to destroy bone and cartilage. Although the causes of RA remain enigmatic, some light has been shed on the mechanisms leading to the disease, which comprise – among other events – overexpression of proinflammatory cytokines.1, 2 Surrogates of inflammation include
The central role of disease activity and its evaluation
The central role of disease activity in the triad is based on its direct causation of disability and its elicitation of joint damage, which – indirectly – leads to functional impairment. Thus, control of disease activity is the pivotal therapeutic goal in RA. This has clearly been shown in a multitude of studies, including trials on the effects of various therapies, such as biologic agents16, 17, 18, 19, 20, 21, 22, and investigations aiming at analyzing management strategies23, 24: more
The obstacles to following disease activity
Controlling disease activity by virtue of evaluating its clinical and laboratory characteristics has been a challenge in rheumatology. Reliable evaluation has been possible for about a decade, using the RA core set variables25, 26, 27 and response criteria or indices that reflect improvement on therapeutic intervention or actual disease activity.28, 29, 30 However, it is still not easy to motivate rheumatologists to utilize such methods in routine practice, and even distributing questionnaires
Traditional instruments to evaluate disease activity and its improvement
Over the decades, numerous scores or response criteria have been developed to evaluate disease activity at a single time point or (absolute or relative) improvement of disease activity.32 In the 1990s, the American College of Rheumatology (ACR) developed response criteria28 based on the improvement of the ACR Core Data Set variables. These were designed to differentiate between active treatment and placebo in clinical trials. The criteria have limitations in clinical practice because they
SDAI and CDAI
After nearly a decade, a new generation of scores has been developed, in line with current insights about the importance of close monitoring of patients and the value of active involvement of patients in the process of controlling disease activity in other fields of medicine.39, 40 Major limitations with the earlier scoring systems were the complexity of the then-available indices, such as those based on the DAS, which were obstacles to effective patient involvement and consequential clinical
Summary
Evaluation of disease activity in RA is not trivial. No single marker can reflect all aspects of the disease. Disease activity instruments – such as scores, criteria, and indices – have significantly improved the ability of the rheumatologist to evaluate the course of RA. All that is required is the performance of formal joint counts, which is not an unreasonable requirement for physicians dealing with joint diseases. Reduced joint counts, which are highly reliable, facilitate joint assessment
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2023, Clinical and Experimental Rheumatology