Published: 2022-01-28

Comparative study of DAS-28 ESR and DAS-28 CRP in determining the severity of disease activity in patients with rheumatoid arthritis

Yousef Mohammadi-Kebar, Ahad Azami, Farhad Pourfarzi, Ashkan Naghavinia


Background: Rheumatoid arthritis is a systemic and chronic disease. Combined indicators, such as disease activity score or DAS-28, can be used to categorize quantitative disease activity status and recovery. But in this calculation there is no difference between using ESR or CRP. Some studies have showed that using CRP instead of ESR will cause the severity of the disease to be underestimated. The aim of this study was to comparison of DAS-28 ESR and DAS-28 CRP in determining the severity of disease activity in patients with rheumatoid arthritis.

Methods: This study was a cross-sectional and descriptive-analytical study on patients with rheumatoid arthritis who referred to the rheumatology clinic of Imam Khomeini Hospital. 200 patients from the target community who referred to the rheumatology clinic were randomly selected and studied. Relevant questionnaires including demographic information such as age, sex, cigar consumption were completed from the study.

Results: In this study, 200 patients with RA who met the inclusion criteria were randomly selected and evaluated. The results showed that the mean age of participants in the study was 50.38±12.82 and those in the age range of 18. They were up to 90 years old and 20% of the people were men and the rest were women. The study on alcohol and cigarette use in patients showed that 3 cases (1.5%) of patients had a history of alcohol consumption and 9 cases (4.5%) had a history of smoking. Examination of DAS28 in individuals showed that the mean of DAS28 in terms of CRP in patients is lower than the mean score of DAS28 in terms of ESR DAS28 showed less disease activity in terms of CRP and this difference was statistically significant (p=0.001). There was no significant relationship between gender, age and serum albumin level with DAS28 score based on ESR and CRP. There was no statistically significant relationship between VAS in patients and DAS28.

Conclusions: According to the results of the present study and previous studies, it seems that if CRP is used to determine the severity of the disease, it is better to use a new scoring criterion for patients.


DAS28-CRP, DAS28-ESR, Rheumatoid arthritis

Full Text:



Albrecht K, Zink A. Poor prognostic factors guiding treatment decisions in rheumatoid arthritis patients: a review of data from randomized clinical trials and cohort studies. Arthritis Res Ther. 2017;19(1):68-74.

Romanowska-Próchnicka K, Olesiñska M, Paradowska-Gorycka A, Mañczak M, Felis-Giemza A, Wojdasiewicz P, et al. Discrepancies in assessment of patients with rheumatoid arthritis and secondary Sjögren’s syndrome by DAS28-ESR and DAS28-CRP. Cent Eur J Immunol. 2016;41(2):188-94.

Fleischmann RM, Van Der Heijde D, Gardiner PV, Szumski A, Marshall L, Bananis E. DAS28-CRP and DAS28-ESR cut-offs for high disease activity in rheumatoid arthritis are not interchangeable. RMD Open. 2017;3(1):2-7.

Tanaka Y, Smolen JS, Jones H, Szumski A, Marshall L, Emery P. The effect of deep or sustained remission on maintenance of remission after dose reduction or withdrawal of etanercept in patients with rheumatoid arthritis. Arth Res Therap. 2019;21(1):164.

Futó G, Somogyi A, Szekanecz Z. Visualization of DAS28, SDAI, and CDAI: the magic carpets of rheumatoid arthritis. Clin Rheumatol. 2014;33(5):623-9.

Bensen WG, Bensen W, Deamude M, Mech C, Bensen R, Lau AN, et al. Validation of snapshot, a rheumatoid arthritis assessment tool, against Cdai, DAS28 (ESR), and DAS28 (CRP) in Canadian patients with rheumatoid arthritis. Arth Rheumatol. 2014;66:S156.

Maas A, Ende CHM, Eerd J, Fransen J, Broeder AA. The use of different methods for rapid determination of the ESR induces DAS28 misclassification in clinical practice. Clin Exp Rheumatol. 2010;28(4):477-82.

Hirabayashi Y, Ishii T. The DAS28-ESR cutoff value necessary to achieve remission under the new Boolean-based remission criteria in patients receiving tocilizumab. Clin Rheumatol. 2013;32(1):123-7.

Sheehy C, Evans V, Hasthorpe H, Mukhtyar C. Revising DAS28 scores for remission in rheumatoid arthritis. Clin Rheumatol. 2014;33(2):269-72.

Ton E, Bakker MF, Verstappen SMM, Ter Borg EJ, Van Albada-Kuipers IA, Schenk Y, et al. Look beyond the disease activity score of 28 joints (DAS28): tender points influence the DAS28 in patients with rheumatoid arthritis. J Rheumatol. 2012;39(1):22-7.

Madsen OR. Is DAS28-CRP with three and four variables interchangeable in individual patients selected for biological treatment in daily clinical practice? Clin Rheumatol. 2011;30(12):1577-82.

Fleischmann R, Van Der Heijde D, Koenig AS, Pedersen R, Szumski A, Marshall L, et al. How much does disease activity score in 28 joints ESR and CRP calculations underestimate disease activity compared with the simplified disease activity index? Ann Rheum Dis. 2015;74(6):1132-7.

Matsui T, Kuga Y, Kaneko A, Nishino J, Eto Y, Chiba N, et al. Disease activity score 28 (DAS28) using C-reactive protein underestimates disease activity and overestimates EULAR response criteria compared with DAS28 using erythrocyte sedimentation rate in a large observational cohort of rheumatoid arthritis patients in Japan. Ann Rheum Dis. 2007;66(9):1221-6.

Ahmadzadeh A, Moslemizadeh M, Imam M, Rajaee A, Shafiezadeh M, Azargashb E, et al. Study of bone turnover markers and inflammatory disease activity in rheumatoid arthritis patients visiting rheumatology clinic of Loghman Hospital during 2008-09. RJMS. 2010;17(78 and 79):1-10.

Madsen OR. Agreement between the DAS28-CRP assessed with 3 and 4 variables in patients with rheumatoid arthritis treated with biological agents in the daily clinic. J Rheumatol. 2013;40(4):379-85.

Oguro N, Yajima N, Miwa Y. Age and quality of life in patients with rheumatoid arthritis treated with biologic agents. Mod Rheumatol. 2020;30(1):44-9.

Kievit W, Welsing PM, Adang EM, Eijsbouts AM, Krabbe PF, Van Riel PL. Comment on the use of self‐reporting instruments to assess patients with rheumatoid arthritis: the longitudinal association between the DAS28 and the VAS general health. Arth Care Res. 2006;55(5):745-50.

Chen S, Ying H, Du J, Zhu X, Shi J, Zhang Y, et al. The association between albumin‐dNLR score and disease activity in patients with rheumatoid arthritis. J Clin Lab Analysis. 2019;33(3):e22695.