Counseling Points - November 2008 - (Page 7)

duration is divided into 3 categories: 24 months—long disease duration.12 Poor prognostic factors that worsen RA outcome include a high number of tender and swollen joints, evidence of radiographic erosions, elevated rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP) antibodies, elevated sedimentation rate (ESR), and/or elevated C-reactive protein (CRP) level. Older age, female sex, HLA-DRB1-positive genotype, worse physical functioning based on HAQ score, and cigarette smoking are also considered poor prognostic factors.12 and/or swollen joint is counted as 1 and the total is tallied at the end. There is no score assigned to a replaced joint.5 Disease Activity Score (DAS) The DAS includes a number of different assessment components, such as swollen joint count, tender joint count, patient global assessment, and sedimentation rate.14 When the DAS was first introduced, 44 joints were counted—the sternoclaviculars, acromioclaviculars, shoulders, elbows, wrists, metacarpophalangeals (MCPs), proximal interphalangeals (PIPs), knees, ankles, and metatarsophalangeals (MTPs). Currently, the more commonly administered shorter DAS28 excludes joints of the feet due to the fact that an inaccurate count could be influenced by calluses and fatty foot pads.14 Tools to Measure Disease Activity Although abundant research has been conducted to identify biomarkers for treatment response, no single clinical or laboratory marker currently exists that allows clinicians to predict how efficacious a drug will be in a particular patient.5,6,13 However, clinicians most often rely on disease index tools to measure patient response to selected therapies. Disease activity is classified as low, moderate, or high based on an RA patient’s score on specific measurement tools, which include the Disease Activity Scale (DAS28), Simpliﬁed Disease Activity Index, Clinical Disease Activity Index, the ACR 20/50/70, and others.12 Nurses and billing personnel should be aware that there is a growing use of validated measurement tools in the reimbursement arena, and insurance companies are using scores from these instruments to evaluate use of expensive biologic agents. Additionally, disease activity tools provide objective data in justifying adjunct services and in completion of disability forms and letters of necessity. Measuring Improvement The ACR has developed its own scoring system known as the ACR 20/50/70 to assess disease improvement (Table 3). This evaluation includes seven measures: swollen joint count, tender joint count, patient global assessment, ESR or CRP level, physical function, pain, and physician global assessment. 2,12 To score an ACR 20, the patient must Table 3. American College of Rheumatology’s Definition of 20% Improvement in RA2 Disease Activity Measure Number of tender joints Number of swollen joints Patient’s assessment of pain Patient’s global assessment of disease activity Physician’s global assessment of disease activity Patient’s assessment of physical function Markers of inflammation (ESR, CRP) Requirement Joint Count A joint count assesses swelling and tenderness in the joints primarily affected by RA and is an accurate measurement of disease over time.5 The assessor, usually a rheumatologist or other rheumatology health professional, palpates the joint, feeling for synovitis. A boggy, spongy area on or around the joint indicates the presence of synovitis. The patient is asked to state if there is any pain or tenderness as each joint is examined. The clinician then rates swelling and/or tenderness as either present or absent. Each tender 7 } ≥20% improvement ≥20% improvement ≥20% improvement on 3 of these 5 measures CRP=C-reactive protein; ESR=erythrocyte sedimentation rate. NOVEMBER 2008

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