In the JournalsPerspective

ACR permits use of multibiomarker disease activity score in updated RA recommendations

Bryant England

The 2019 update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures now includes a stipulation to allow for use of the multibiomarker disease activity score, a key update from the previous iteration.

“The ACR put together a working group to provide the recommendations and draft the protocol for making recommendations,” Bryant England, MD, assistant professor in the division of rheumatology and immunology at the University of Nebraska Medical Center, told Healio Rheumatology. “We started by conducting a systematic literature review of RA disease activity measures since the time of the last recommendations.”

England and colleagues identified 5,199 articles pertaining to RA disease activity measures, and ultimately included 110 in the final review. The researchers then assessed the performance of these measures using a scoring tool and their feasibility for regular use in the clinic.

“Finally, we performed a modified Delphi process to provide the recommendations on measures that met a minimum standard as well as preferred RA disease activity measures for regular use,” England said.

The 2019 update of the American College of Rheumatology recommended RA disease activity measures now includes a stipulation to allow for use of the multibiomarker disease activity score, a key update from the previous iteration.

Forty-six potential RA disease activity measures underwent analysis, including measures for patient, provider, laboratory and/or imaging data, according to the findings. Ultimately, the researchers recommended five disease activity measures for regular use in clinical practice: DAS28 with Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP); Clinical Disease Activity Index (CDAI); Simplified Disease Activity Index (SDAI); Routine Assessment of Patient Index Data (RAPID) 3 and; Patient Activity Scale (PAS) II.

“Five of the six previously recommended RA disease activity measures were again recommended,” England said. “The performance of these measures is well understood, they have been integrated into clinical settings widely, and they continue to be the focus of many research studies.”

The other measures that did not make the cut for use in regular clinical practice, but did meet minimum standards for regular use include the RAPID 5; the Hospital Universitario La Princesa Index (HUPI), MBDA score, Rheumatoid Arthritis Disease Activity Index (RADAI) and RADAI-5.

England noted that the selection of all of these measures offers clinicians latitude to inform clinical decision-making. “To provide clinicians with more options, we also provided a list of measures that met our minimum standard for regular use,” he said. “Reasons these were not selected as preferred measures include less clarity on their performance and not being as feasible for regular use.”

Perhaps the most striking addition to the recommendations is for the MBDA. “This disease activity measure provides an overall score from 0 to 100 based on the values of 12 serum biomarkers,” England said. “Based on its performance characteristics and feasibility, it fulfilled the minimum standards for regular use. However, the MBDA was not selected as a preferred RA disease activity measure for regular use.”

The researchers recognized that many providers may have attachments to certain measures, according to England.

“This attachment can be based on familiarity with its use and performance, or because the provider’s practice setting may work best with a certain RA disease activity measure,” he said. “This is why we established the minimum standard for RA disease activity measures for regular use and identified the measures that met this standard. While providers are free to choose the measure that works best in their practice, we recommend selecting a preferred measure if they are looking for a RA disease activity measure to use in their practice.” – by Rob Volansky

Disclosure: England reports no relevant financial disclosures. 

Bryant England

The 2019 update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures now includes a stipulation to allow for use of the multibiomarker disease activity score, a key update from the previous iteration.

“The ACR put together a working group to provide the recommendations and draft the protocol for making recommendations,” Bryant England, MD, assistant professor in the division of rheumatology and immunology at the University of Nebraska Medical Center, told Healio Rheumatology. “We started by conducting a systematic literature review of RA disease activity measures since the time of the last recommendations.”

England and colleagues identified 5,199 articles pertaining to RA disease activity measures, and ultimately included 110 in the final review. The researchers then assessed the performance of these measures using a scoring tool and their feasibility for regular use in the clinic.

“Finally, we performed a modified Delphi process to provide the recommendations on measures that met a minimum standard as well as preferred RA disease activity measures for regular use,” England said.

The 2019 update of the American College of Rheumatology recommended RA disease activity measures now includes a stipulation to allow for use of the multibiomarker disease activity score, a key update from the previous iteration.

Forty-six potential RA disease activity measures underwent analysis, including measures for patient, provider, laboratory and/or imaging data, according to the findings. Ultimately, the researchers recommended five disease activity measures for regular use in clinical practice: DAS28 with Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP); Clinical Disease Activity Index (CDAI); Simplified Disease Activity Index (SDAI); Routine Assessment of Patient Index Data (RAPID) 3 and; Patient Activity Scale (PAS) II.

“Five of the six previously recommended RA disease activity measures were again recommended,” England said. “The performance of these measures is well understood, they have been integrated into clinical settings widely, and they continue to be the focus of many research studies.”

The other measures that did not make the cut for use in regular clinical practice, but did meet minimum standards for regular use include the RAPID 5; the Hospital Universitario La Princesa Index (HUPI), MBDA score, Rheumatoid Arthritis Disease Activity Index (RADAI) and RADAI-5.

England noted that the selection of all of these measures offers clinicians latitude to inform clinical decision-making. “To provide clinicians with more options, we also provided a list of measures that met our minimum standard for regular use,” he said. “Reasons these were not selected as preferred measures include less clarity on their performance and not being as feasible for regular use.”

Perhaps the most striking addition to the recommendations is for the MBDA. “This disease activity measure provides an overall score from 0 to 100 based on the values of 12 serum biomarkers,” England said. “Based on its performance characteristics and feasibility, it fulfilled the minimum standards for regular use. However, the MBDA was not selected as a preferred RA disease activity measure for regular use.”

The researchers recognized that many providers may have attachments to certain measures, according to England.

“This attachment can be based on familiarity with its use and performance, or because the provider’s practice setting may work best with a certain RA disease activity measure,” he said. “This is why we established the minimum standard for RA disease activity measures for regular use and identified the measures that met this standard. While providers are free to choose the measure that works best in their practice, we recommend selecting a preferred measure if they are looking for a RA disease activity measure to use in their practice.” – by Rob Volansky

Disclosure: England reports no relevant financial disclosures. 

    Perspective
    Leonard H. Calabrese

    Leonard H. Calabrese

    I am pleased to see the updated recommendations from an esteemed group working on behalf of ACR identified 11 measures to assess RA disease activity that met minimum standard for regular use and five preferred for regular use in practice.

    Although the core measurements endorsed as preferred for regular use are largely unchanged from the previous iteration of these recommendations, the additional endorsed metrics now include the MBDA, which is a major change and addition to our armamentarium of tools to manage RA. In the interest of total transparency, I am a consultant to the company who markets this, but I have publicly stated that I came slow to endorse this test, which was introduced nearly 8 years ago.

    The MBDA was introduced as a test that correlated with DAS28, but initially we knew little else about it. The test now has been studied in numerous situations defining its merit for predicting rapid radiographic progression, allowing us to understand its inherent biologic variability and how it is influenced by common comorbidities and providing perspective on what constitutes meaningful change among others. These data are available in scores of articles published in peer review for all of us to make critical appraisals of its value and utility — and on this basis, the data spoke for themselves as the basis for endorsement.

    I wholeheartedly agree with the recommendations that the MBDA is not a test that should be incorporated for “regular use” — that is, measured at each visit — and I do not believe it was ever intended to be used as such. In my opinion, its value as a disease activity measurement is to provide a robust estimation of prognosis, and especially as a tool to help sort out discordance where patients and providers differ in their global assessments. This scenario, which may occur in as many as one in three visits, is often complex and an over-reliance on our “gut feelings” poses real risks of over-treatment, as in 90% of such instances, our patients tell us they are worse than we appraise.

    I believe that these recommendations provide firm ground for each provider to assess what measurements work best for their practice and offer an array of tools to meet the varying needs of our patients.

    • Leonard H. Calabrese, DO
    • Chief medical editor, Healio Rheumatology
      Professor of medicine
      Cleveland Clinic Lerner College of Medicine
      Case Western Reserve University
      RJ Fasenmyer Chair of Clinical Immunology
      Cleveland Clinic

    Disclosures: Dr. Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB.