Open Access Open Badges Research article

Determining a low disease activity threshold for decision to maintain disease-modifying antirheumatic drug treatment unchanged in rheumatoid arthritis patients

Michel de Bandt1*, Bruno Fautrel2, Jean Francis Maillefert3, Jean Marie Berthelot4, Bernard Combe5, René-Marc Flipo6, Frédéric Lioté7, Olivier Meyer8, Alain Saraux9, Daniel Wendling10, Xavier Le Loët11, Francis Guillemin1213 and the STPR group of the French Society of Rheumatology

Author Affiliations

1 Centre hospitalier d'Aulnay sous Bois, Service de Rhumatologie, Boulevard Ballanger, Aulnay sous Bois F-93600, France

2 APHP-GH Pitié Salpêtrière, Service de Rhumatologie, UFR de Médecine, Université Paris VI - Pierre et Marie Curie, 83 boulevard de l'Hôpital, 75651 Paris cedex 13, France

3 Centre Hospitalo-Universitaire du Dijon, Hôpital du Bocage, Service de Rhumatologie, 3 rue du faubourg Raynes, Dijon F-21000, France

4 INSERM ERI 7 (EA 3822), Centre Hospitalo-Universitaire de Nantes, Hotel-Dieu, Service de Rhumatologie, 1 Place Alexis Ricordeau, Nantes F-44000, France

5 Centre Hospitalo-Universitaire du Montpellier, Hôpital Lapeyronie, Service de Rhumatologie, 371 avenue du Doyen Gaston Giraud, Montpellier F-34000, France

6 Centre Régional Hospitalo-Universitaire de Lille, Service de Rhumatologie, Rue du Pr E Laine, Lille F-59000, France

7 Hôpital Lariboisière, Centre Viggo-Petersen, Service de Rhumatologie, 2 rue A Paré, Paris F-75010, France

8 UFR de Médecine - Bichat Lariboisière, Université Paris 7, APHP, Groupe hospitalier Bichat - Claude Bernard, Service de Rhumatologie, 46 rue H Huchard, Paris F-75018, France

9 Centre Hospitalo-Universitaire de Brest, Hôpital de la Cavale Blanche, Service de Rhumatologie, rue T Prigent, Brest F-29000, France

10 EA3186 - Agents pathogènes et Inflammation, Université de Franche-Comté, Centre Hospitalo - Universitaire de Besançon, Hôpital Jean Minjoz, Service de Rhumatologie, 1 Bd Fleming, Besançon F-25000, France

11 Department of Rheumatology, Rouen University Hospital & Inserm U905 (IFRMP 23), University of Rouen, 1 rue de Germont, Rouen F-76230, France

12 INSERM CIC-EC, CHU de Nancy - Hôpital Marin, 92 av Mal de Lattre de Tassigny, 54035 Nancy cedex, France

13 Université Henri Poincaré Nancy I, EA4003, Ecole de Santé Publique, Faculté de Médecine de Nancy, Nancy F-54000, France

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Arthritis Research & Therapy 2009, 11:R157  doi:10.1186/ar2836

Published: 23 October 2009



The aim of this study was to determine a low disease activity threshold - a 28-joint disease activity score (DAS28) value - for the decision to maintain unchanged disease-modifying antirheumatic drug (DMARD) treatment in rheumatoid arthritis patients, based on expert opinion.


Nine hundred and sixty-seven case scenarios with various levels for each component of the DAS28 (resulting in a disease activity score between 2 and 3.2) were presented to 44 panelists. For each scenario, panelists had to decide whether or not DMARD treatment (excluding steroids) could be maintained unchanged. In each scenario, for decision, the participants were given the DAS28 parameters, without knowledge of the resultant DAS28. The relationship between panelists' decision, DAS28 value, and components of the score were analysed by multiple logistic regression analysis. Each panelist analysed 160 randomised scenarios. Intra-rater and inter-rater reproducibility were assessed.


Forty-four panelists participated in the study. Inter-panelist agreement was good (κ = 0.63; 95% confidence interval = 0.61 to 0.65). Intra-panelist agreement was excellent (κ = 0.87; 95% confidence interval = 0.82 to 0.92). Quasi-perfect agreement was observed for DAS28 ≤ 2.4, less pronounced between 2.5 and 2.9, and almost no agreement for DAS28 > 3.0. For values below 2.5, panelists agreed to maintain unchanged DMARDs; for values above 2.5, discrepancies occurred more frequently as the DAS28 value increased. Multivariate analysis confirmed the relationship between panelist's decision, DAS28 value and components of the DAS28. Between DAS28 of 2.4 and 3.2, a major determinant for panelists' decision was swollen joint count. Female and public practice physicians decided more often to maintain treatment unchanged.


As a conclusion, panelists suggested that in clinical practice there is no need to change DMARD treatment in rheumatoid arthritis patients with DAS28 ≤ 2.4.