Centre hospitalier d'Aulnay sous Bois, Service de Rhumatologie, Boulevard Ballanger, Aulnay sous Bois F-93600, France.
Arthritis Res Ther. 2009;11(5):R157. doi: 10.1186/ar2836. Epub 2009 Oct 23.
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 (kappa = 0.63; 95% confidence interval = 0.61 to 0.65). Intra-panelist agreement was excellent (kappa = 0.87; 95% confidence interval = 0.82 to 0.92). Quasi-perfect agreement was observed for DAS28 < or = 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 < or = 2.4.
本研究旨在基于专家意见，确定低疾病活动阈值（DAS28 评分 28 关节），以便决定是否维持类风湿关节炎患者的疾病修饰抗风湿药物（DMARD）治疗不变。
向 44 名专家展示了 967 种不同 DAS28 各组成部分水平的病例情况（导致疾病活动评分在 2 到 3.2 之间）。对于每个病例，专家必须决定是否维持不变 DMARD 治疗（不包括类固醇）。在每个病例中，为了做出决策，参与者除了 DAS28 参数外，不了解由此产生的 DAS28。通过多元逻辑回归分析分析参与者决策、DAS28 值和评分组成部分之间的关系。每位专家分析了 160 个随机病例。评估了内部和外部评分者的可重复性。
44 名专家参加了研究。专家之间的一致性良好（kappa = 0.63；95%置信区间为 0.61 至 0.65）。内部评分者的一致性极好（kappa = 0.87；95%置信区间为 0.82 至 0.92）。DAS28 <或= 2.4 时观察到几乎完全一致，DAS2.5 到 2.9 之间的一致性较差，DAS28 > 3.0 时几乎没有一致性。对于低于 2.5 的值，专家们同意维持不变的 DMARD；对于高于 2.5 的值，随着 DAS28 值的增加，差异出现的频率更高。多变量分析证实了专家决策、DAS28 值和 DAS28 组成部分之间的关系。在 DAS2.4 和 3.2 之间，专家决策的主要决定因素是肿胀关节计数。女性和公共实践医生更倾向于维持治疗不变。
总之，专家们建议在临床实践中，DAS28 <或= 2.4 的类风湿关节炎患者无需改变 DMARD 治疗。
