Original articleEvaluation of spondylarthritis activity by patients and physicians: ASDAS, BASDAI, PASS, and flares in 200 patients
Introduction
Spondyloarthritis is characterized by inflammation of the axial and/or peripheral joints that progresses by flares and remissions. According to the 2011 update of recommendations issued by the European League Against Rheumatism (EULAR) and Assessment in Ankylosing Spondylitis International Society (ASAS), the preferred first-line agents are analgesics and antiinflammatory drugs [1]. The introduction of biologics has broadened the array of options available to specialists and, similar to developments in rheumatoid arthritis, has brought achieving a clinical disease remission among the reasonable treatment objectives [2].
In everyday practice, disease activity and functional impairments in patients with spondylarthritis are evaluated using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI), respectively [3], [4]. The BASDAI has a number of well-documented flaws [5], [6]. Therefore, the ASAS recently developed the Ankylosing Spondylitis Disease Activity Score (ASDAS) based on both clinical and laboratory variables. The ASDAS is a simple, reproducible, and discriminating tool for rapidly separating different disease activity levels [7], although it is not yet used in everyday practice or official recommendations. The ASAS used a Norwegian cohort to identify cutoffs for various levels of disease activity and of treatment-related improvements [8], [9]. Furthermore, ASAS/EULAR recommendations require that the patient's perception of disease activity be taken into account [10]. To this end, the patient-acceptable symptom state (PASS) was defined as a level of well-being found satisfactory by the patient, i.e., as a “yes” answer to the following question: “Considering all the different ways your disease is affecting you, if you would stay in this state for the next months, do you consider that your current state is satisfactory?” A recent study established that the PASS indicated a BASDAI no greater than 3.4/10 [11]. No studies have assessed the ASDAS cutoff associated with the PASS.
The primary objective of this study was to define the ASDAS score below which unselected patients seen in everyday practice were in the PASS. The secondary objectives were to assess agreement between ASDAS and BASDAI; between patient-reported levels of disease activity and the ASDAS and BASDAI cutoffs; and between the two ASDAS values obtained using the C-reactive protein (CRP) level and the erythrocyte sedimentation rate (ESR), respectively. We also assessed the potential psychological impact of spondyloarthritis. Finally, our last objective was to identify BASDAI and ASDAS cutoffs indicating a flare and those indicating a remission, as determined by the physician and by the patient.
Section snippets
Scores
The ASDAS is obtained using an equation based on subjective items from the BASDAI and on an objective laboratory item (CRP or ESR). The ASAS recommends using the CRP and indicates that the same laboratory variable should be used throughout the follow-up of a given patient [9]. We computed both the ASDAS-CRP and the ASDAS-ESR whenever possible but used only the ASDAS-CRP for the data analyses.
To evaluate the psychological impact of spondyloarthritis, we asked the patient to complete the 13-item
Results
We included 200 patients, of whom 32.6% were seen at least twice at the outpatient clinic or day-hospital during the study period.
Discussion
Disease activity in patients with spondyloarthritis is traditionally evaluated using the BASDAI, although the newer ASDAS is increasingly used instead. The BASDAI has a number of well-documented flaws [15]. For instance, it correlated less well with physician evaluations, compared to the ASDAS [6]. Here, our primary objective was to identify cutoffs corresponding to the PASS, since few studies have assessed the impact of spondyloarthritis on quality of life [16], [17], [18]. We found that
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
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