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DAS28 – Disease Activity Score in Rheumatoid Arthritis

The DAS28 is a validated score used to measure disease activity in rheumatoid arthritis. It combines joint assessments, inflammatory markers, and patient self-assessment.

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Things worth knowing about "DAS28"

The DAS28 is a validated score used to measure disease activity in rheumatoid arthritis. It combines joint assessments, inflammatory markers, and patient self-assessment.

What is the DAS28?

The DAS28 (Disease Activity Score 28) is a standardized tool used to assess the disease activity in rheumatoid arthritis (RA). Developed in the 1990s, it is one of the most widely used instruments in rheumatology worldwide. The number 28 refers to the 28 joints that are systematically evaluated during the assessment.

How is the DAS28 Calculated?

The DAS28 is composed of four components that are entered into a mathematical formula:

Tender Joint Count (TJC28): The number of joints that are painful when pressed.
Swollen Joint Count (SJC28): The number of joints with palpable swelling.
Inflammatory marker: Either the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), depending on the version used (DAS28-ESR or DAS28-CRP).
Patient global assessment: The patient rates their overall health status on a visual analogue scale (VAS) from 0 to 100 mm.

The 28 joints assessed include: shoulders, elbows, wrists, metacarpophalangeal joints (MCP), proximal interphalangeal joints (PIP), and knees.

Interpreting DAS28 Values

The calculated score ranges from 0 to approximately 9.4. The standard classification is as follows:

DAS28 ≤ 2.6: Remission (no significant disease activity)
DAS28 > 2.6 to ≤ 3.2: Low disease activity
DAS28 > 3.2 to ≤ 5.1: Moderate disease activity
DAS28 > 5.1: High disease activity

A key treatment target in rheumatoid arthritis is achieving remission (DAS28 ≤ 2.6) or at least low disease activity.

Clinical Relevance

In clinical practice, the DAS28 is regularly used to:

objectively document the course of rheumatoid arthritis,
monitor treatment response and adjust therapy as needed,
support decisions regarding the use of biologics or other disease-modifying antirheumatic drugs (DMARDs),
enable comparisons between treatment strategies in clinical trials.

Many health authorities and clinical guidelines (e.g., EULAR guidelines) use the DAS28 as a basis for treatment decisions, particularly when approving the use of biologic therapies.

Limitations of the DAS28

Despite its widespread use, the DAS28 has some limitations:

It does not include all joints — notably the hips, ankles, and toe joints are excluded.
It may overestimate or underestimate disease activity in certain patients, for example those with fibromyalgia or very high CRP levels.
The remission threshold of the DAS28 is less stringent than other remission definitions, such as the Boolean remission criteria proposed by ACR/EULAR.

References

Prevoo ML 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 & Rheumatism, 1995.
Smolen JS et al. – EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Annals of the Rheumatic Diseases, 2023.
Aletaha D, Smolen JS – The Disease Activity Score (DAS) and its role as an outcome measure in rheumatoid arthritis. Clinical and Experimental Rheumatology, 2005.

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