Krankheitsaktivitätsmessung bei der Rheumatoiden Arthritis – Warum können wir auf Joint Counts in der Routine verzichten

Zusammenfassung

Die Kranheitsaktivität der rheumatoiden Arthritis (RA) wird in klinischen Studien mit Aktivitätsscores gemessen, die auf einen rheumatologischen Gelenkstatus basieren. Das Erheben von druckschmerzhaften und geschwollenen Gelenken ist dafür unumgänglich. Solch ein Status ist zeitaufwändig und setzt entsprechende Erfahrung voraus. Studien belegen, dass eine hohe inter-Observer Varianz besteht. RA Patienten werden jedoch viel zu selten vom rheumatologischen Facharzt gesehen und nicht einmal diese haben im klinischen Alltag oftmals die Zeit einen solchen Status zu erheben. Patientenzentrierte Scores wie der RADAI-5 oder der RAPID-3 haben gezeigt, dass sie sehr sensibel die Aktivität der RA anzeigen, ja sogar mit geschwollenen und druckschmerzhaften Gelenken signifikant korrelieren beziehungsweise mit Composite Scores wie dem DAS28 oder CDAI. Daher könnten patientenzentrierte Aktivitätsscores zur engmaschigeren Dokumentation des Krankheitsverlaufes im klinischen Alltag einen wesentlichen Beitrag leisten, da der Patient selbst ohne Hilfe diesen aufzeichnen kann und das Errechnen der Scores einen minimalen Zeitaufwand für den behandelnden Arzt darstellt.

Abstract

In clinical trials the disease activity of rheumatoid arthritis (RA) is assessed by scores based on tender and swollen joint counts. These joint counts are time-consuming and require experience in joint assessment. Studies have demonstrated that inter-observer variance in joint assessment is particularly high. RA patients unfortunately are seen only rarely by rheumatologists and even in a busy clinical setting the rheumatologist often does not have enough time to perform a formal rheumatological assessment. Patient-centred disease activity scores for RA such as the RADAI-5 or the RAPID-3 constitute an alternative for busy clinical settings since these short questionnaires are to be completed by the patient him-/herself. They have been shown to exhibit a significant correlation to common composite disease activity scores, such as the DAS28 and the CDAI, as well as to swollen and tender joint counts. And, as a further advantage, these scores require minimal costs and professional time.

Schlüsselwörter

Kranankheitsaktivität - DAS28 - RADAI-5 - rheumatoide Arthritis

Key words

disease activity - DAS28 - RADAI-5 - rheumatoide arthritis

Literatur

• 1 Arnett FC, Edworthy SM, Bloch DA. et al . The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.  Arthritis Rheum. 1988;  31 315-324
• 2 Grigor C, Capell H, Stirling A. et al . Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial.  Lancet. 2004;  364 ((9430)) 263-269
• 3 Pincus T, Segurado OG. Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count.  Ann Rheum Dis. 2006;  65 ((6)) 820-822
• 4 Hart LE, Tugwell P, Buchanan WW. et al . Grading of tenderness as a source of interrater error in the Ritchie articular index.  J Rheumatol. 1985;  12 ((4)) 716-717
• 5 Klinkhoff AV, Bellamy N, Bombardier C. et al . An experiment in reducing interobserver variability of the examination for joint tenderness.  J Rheumatol. 1988;  15 492-494
• 6 Garrett S, Jenkinson T, Kennedy LG. et al . A new approach to defining disease status in ankylosing spondylitis: the development of the bath ankylosing spondylitis disease activity index.  J Rheumatol. 1994;  21 2286-2291
• 7 Fries JF, Spitz P, Kraines RG. et al . Measurements of patient outcomes in arthritis.  Arthritis Rheum. 1980;  23 137-145
• 8 Wolfe F, Michaud K, Gefeller O. et al . Predicting mortality in patients with rheumatoid arthritis.  Arthritis Rheum. 2003;  48 ((6)) 1530-1542
• 9 Prevoo ML, van’t Hof MA, Kuper HH. et al . Modified disease activity scores that include twenty-eight-joint counts: development and validation in a prospective longitudinal study of patients with rheumatoid arthritis.  Arthritis Rheum. 1995;  38 44-48
• 10 Smolen JS, Breedveld FC, Schiff MH. et al . A simplified disease activity index for rheumatoid arthritis for use in clinical practice.  Rheumatology (Oxford). 2003;  42 244-257
• 11 Aletaha D, Nell VP, Stamm T. et al . Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score.  Arthritis Res Ther. 2005;  7 ((4)) R796-R806
• 12 Felson DT, Anderson JJ, Boers M. et al . American College of Rheumatology: preliminary definition of improvement in rheumatoid arthritis.  Arthritis Rheum. 1995;  38 727-735
• 13 Yazici Y, Bergman M, Pincus T. Time to score quantitative rheumatoid arthritis measures: 28-Joint Count, Disease Activity Score, Health Assessment Questionnaire (HAQ), Multidimensional HAQ (MDHAQ), and Routine Assessment of Patient Index Data (RAPID) scores.  J Rheumatol. 2008;  35 603-609
• 14 Rintelen B, Sautner J, Haindl PM. et al . Comparison of Three Rheumatoid Arthritis Disease Activity Scores in Clinical Routine.  Scand J Rheumatol. 2009;  , [in press]
• 15 Stucki G, Liang MH, Stucki S. et al . A self-administered Rheumatoid Arthritis Disease Activity Index (RADAI) for epidemiologic research: psychometric properties and correlation with parameters of disease activity.  Arthritis Rheum. 1995;  38 795-798
• 16 Fransen J, Langenegger T, Michel BA. et al . Feasibility and validity of the RADAI, a self-administered rheumatoid arthritis disease activity index.  Rheumatology. 2000;  39 321-327
• 17 Leeb BF, Haindl PM, Maktari A. et al . Patient-Centered Rheumatoid Arthritis Disease Activity Assessment By A Modified RADAI.  J Rheumatol. 2008;  35 1294-1299
• 18 Rintelen B, Haindl PM, Sautner J. et al . The RADAI-5 in daily use. Proposal for Disease Activity Categories.  J Rheumatol. 2009;  , [Epub ahead of print]
• 19 Pincus T, Swearingen CJ, Bergman N. et al . RAPID3 (Routine Assessment of Patient Index Data 3), a rheumatoid arthritis index without formal joint counts for routine care: proposed severity categories compared to disease activity score and clinical disease activity index categories.  , J Rheumatol 2008;  35 2136-2147
• 20 Pincus T, Bergman MJ, Yazici Y. et al . An index of only patient-reported outcome measures, routine assessment of patient index data 3 (RAPID3), in two abatacept clinical trials: similar results to disease activity score (DAS28) and other RAPID indices that include physician-reported measures.  Rheumatology. 2008;  47 345-349
• 21 Puolakka K, Kautiainen H, Möttönen T. et al . FIN-RACo Trial Troup. Predictors of productivity loss in early rheumatoid arthritis: a 5 year follow up study.  Ann Rheum Dis. 2005;  64 130-133
• 22 Dougados M, Schmidely N, Le Bars M. et al . Evaluation of different methods used to assess disease activity in rheumatoid arthritis: analyses of abatacept clinical trial data.  Ann Rheum Dis. , published online 11 Dec 2008
• 23 Fransen J, Häuselmann H, Michel BA. et al . Responsiveness of the self-assessed rheumatoid arthritis disease activity index to a flare of disease activity.  Arthritis Rheum. 2001;  44 53-60
• 24 Leeb BF, Haindl PM, Maktari A. et al . Disease Activity Score-28 Values Differ Considerably Depending on Patient’s Pain Perception and Sex.  J Rheumatol. 2007;  34 2382-2387
• 25 Rintelen B, Haindl PM, Nothnagl T. et al . SDAI/CDAI-Levels in Rheumatoid Arthritis Patients are Highly Determined by Patient’s Pain Perception and Gender.  Scand J Rheumatol. 2008;  29 1-4
• 26 Pincus T, Amara I, Seguardo OG. et al . Relative efficiencies of physician/assessor global estimates and patient questionnaire measures are similiar to or greater than joint counts to distinguish adalimumab from control treatments in rheumatoid arthritis clinical trials.  J Rheumatol. 2008;  35 201-205
• 27 Pincus T. Limitations of a quantitative swollen and tender joint count to assess and monitor patients with rheumatoid arthritis.  Bull NYU Hosp Jt Dis. 2008;  66 216-223
• 28 Wolfe F, Pincus T, Thompson AK. et al . The assessment of rheumatoid arthritis and the acceptability of self-report questionnaires in clinical practice.  Arthritis Rheum. 2003;  49 59-63
• 29 Hetland ML, Stengaard-Pedersen K, Junker P. et al . CIMESTRA Study Group. Combination treatment with methotrexate, cyclosporine, and intraarticular betamethasone compared with methotrexate and intraarticular betamethasone in early active rheumatoid arthritis: an investigator-initiated, multicenter, randomized, double-blind, parallel-group, placebo-controlled study.  Arthritis Rheum. 2006;  54 1401-1409
• 30 Wakefield RJ, Green MJ, Marzo-Ortega H. et al . Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease.  Ann Rheum Dis. 2004;  63 382-385
• 31 Kane D, Balint PV, Sturrock RD. Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis.  J Rheumatol. 2003;  30 966-971
• 32 Criswell LA, Such CL, Neuhaus JM. et al . Variation among rheumatologists in clinical outcomes and frequency of office visits for rheumatoid arthritis.  J Rheumatol. 1997;  24 1266-1271
• 33 Pincus T, Sokka T. Quantitative Clinical Assessment in Busy Rheumatological Settings: the Value of Short Patient Questionnaires.  J Rheumatol. 2008;  35 1235-1237

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