|Year : 2018 | Volume
| Issue : 2 | Page : 43-48
Using Rheumatoid Arthritis Disease Activity Index-5 questionnaire in the assessment of disease activity in patients with rheumatoid arthritis: correlation with quality of life, pain, and functional status
Shereen R Kamel
Department of Rheumatology and Rehabilitation, Minia University, Minia, Egypt
|Date of Submission||23-Jun-2017|
|Date of Acceptance||20-Aug-2017|
|Date of Web Publication||2-Apr-2018|
Shereen R Kamel
Minia University Hospital, Minya 6111
Source of Support: None, Conflict of Interest: None
Objective The aim of our study was to assess the disease activity in patients with rheumatoid arthritis (RA) using Rheumatoid Arthritis Disease Activity Index-5 (RADAI‑5) questionnaire and to find its correlation with Disease Activity Score-28 (DAS28), quality of life, pain, and functional status.
Patients and methods A total of 40 patients with RA were included. Quality of life was evaluated by Quality of Life–Rheumatoid Arthritis scale. The severity of pain was measured by 100-mm visual analog scale-pain. Health Assessment Questionnaire Disability Index was used to evaluate functional status. Disease activity was measured by using the DAS28 and RADAI-5.
Results Mean RADAI-5 score was 4.2±1.7 (moderate disease activity). A total of seven (17.5%) patients were in remission, four (10%) patients had mild disease activity, 19 (47.5%) patients had moderate disease activity, and 10 (25%) patients had high disease activity. RADAI-5 was significantly correlated with DAS28, quality of life scale, pain scale, and functional status (r=0.9, P<0.001; r=0.9, P<0.001; r=0.4, P=0.02; and r=0.6, P<0.001, respectively). Moreover, RADAI-5 was found to be significantly correlated with morning stiffness duration, Ritchie articular index, tender 28-joint count, swollen 28-joint count, erythrocyte sedimentation rate, anticyclic citrullinated peptide, and rheumatoid factor positivity (r=0.3, P=0.03; r=0.8, P<0.001; r=0.9, P<0.001; r=0.7, P<0.001; r=0.6, P<0.001; r=0.6, P<0.001; and r=0.4, P=0.008, respectively).
Conclusion RADAI-5 is a simple and low-cost self-report questionnaire that reflects patients’ perception of signs and symptoms. The correlations of RADAI-5 with DAS28, quality of life, pain, and functional status reflect its value in the assessment of disease activity in patients with RA.
Keywords: functional status, quality of life, Rheumatoid Arthritis Disease Activity Index-5, rheumatoid arthritis
|How to cite this article:|
Kamel SR. Using Rheumatoid Arthritis Disease Activity Index-5 questionnaire in the assessment of disease activity in patients with rheumatoid arthritis: correlation with quality of life, pain, and functional status. Egypt Rheumatol Rehabil 2018;45:43-8
|How to cite this URL:|
Kamel SR. Using Rheumatoid Arthritis Disease Activity Index-5 questionnaire in the assessment of disease activity in patients with rheumatoid arthritis: correlation with quality of life, pain, and functional status. Egypt Rheumatol Rehabil [serial online] 2018 [cited 2019 Jul 17];45:43-8. Available from: http://www.err.eg.net/text.asp?2018/45/2/43/229017
| Introduction|| |
Rheumatoid arthritis (RA) is a progressive inflammatory disease that causes damage and disability , which can be prevented by promptly initiated and effective therapy ,,. To ensure that therapy is effective, frequent clinical assessments are needed ,.
Various disease activity scales have been used for measuring disease activity in RA. Composite indexes, such as the Disease Activity Score (DAS), including a 44-joint or a 28-joint count (DAS28), have been successfully used, particularly in clinical trials ,; however, they are long and may interfere with the flow of patient visits rather than contributing information to clinical care . For busy clinical settings, Leeb et al.  developed a simplified version of the Rheumatoid Arthritis Disease Activity Index (RADAI) questionnaire, RADAI-5. RADAI-5 is a newly developed tool that is physician as well as patient friendly and can be completed within a minute .
Applying the RADAI-5 in daily routine provides the patient’s view at any time by completing the questionnaire . Practicing rheumatologists increasingly do not have enough time to perform joint counts at every patient visit or they think that they do not have. Thus, there is evidence that most visits by patients with RA to rheumatologists do not include a formal joint count, which, however, is a prerequisite for the calculation of the respective indexes .
To our knowledge, there is no published Egyptian experience available with RADAI-5 till date. The aim of our study was to assess the disease activity in patients with RA using RADAI‑5 and to find its correlation with DAS28, quality of life, pain, and functional status.
| Patients and methods|| |
A total of 40 consecutive patients (33 female and seven male) who fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria  were included in the present study. All patients were attending the outpatient rheumatology clinic, Minia University Hospitals. Informed consent was taken from all participants in the study. The study was approved by the ethics committee of the Faculty of Medicine.
Patients who had severe anemia, hypothyroidism, and pulmonary, cardiac, liver, or renal disease were excluded from the study.
The swollen 28-joint count (SJC28) and tender 28-joint count (TJC28), Ritchie articular index (RAI) , anticyclic citrullinated peptide, rheumatoid factor, and erythrocyte sedimentation rate (ESR) were assessed. Quality of life was evaluated by Quality of Life–Rheumatoid Arthritis (QOLRA) scale . The severity of pain was measured by 100-mm visual analog scale-pain . Health Assessment Questionnaire Disability Index was used to evaluate functional status . Disease activity was measured by using DAS28  and RADAI-5 .
RADAI-5 is a five-item, self-administered RA-specific questionnaire that assesses global disease activity in the past 6 months and current disease activity in terms of joint swelling and tenderness, pain, duration of morning stiffness, and general health. The result can be easily calculated as follows: (Q1+Q2+Q3+Q4+Q5)/5 ([Figure 1]). Scores between 0.0 and 1.4 indicate remission, 1.6 and 3.0 low disease activity, 3.2 and 5.4 moderate disease activity, and greater than 5.6 high disease activity ,.
|Figure 1 The Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5) questionnaire.|
Click here to view
The statistical analysis was performed using SPSS 16.0 (USA). Descriptive statistics were done by number and percent as well as mean and SD. Correlations were calculated using Pearson’s correlation coefficient. The level of statistical significance was set at a P value less than 0.05.
| Results|| |
A total of 40 patients with RA were included in the present study. Their mean age was 39.2±12.3 years, and their mean disease duration was 5.2±4.9 years. [Table 1] shows demographic, clinical, and laboratory data.
Mean RADAI-5 score was 4.2±1.7 (median: 4.4), indicating moderate disease activity. At the time of the study, seven (17.5%) patients were in remission (RADAI-5: 0–1.4), four (10%) patients had mild disease activity (RADAI-5: 1.6–3.0), 19 (47.5%) patients had moderate disease activity (RADAI-5: 3.2–5.4), and 10 (25%) patients had high disease activity (RADAI-5: >5.6).
Mean DAS28 was 4.3±1.3 (median: 4.2), indicating moderate disease activity. According to DAS28, six (15%) patients were in remission (DAS28≤2.6), two (5%) showed mild activity (DAS28: 2.6–3.2), 19 (47.5%) showed moderate activity (DAS28: 3.2–5.1), and 13 (32.5%) showed high activity (DAS28≥5.1).
RADAI-5 was significantly correlated with DAS28 ([Figure 2]), quality of life scale ([Figure 3]), pain scale, and functional status (r=0.9, P<0.001; r=0.9, P<0.001; r=0.4, P=0.02; and r=0.6, P<0.001, respectively). Correlations of RADAI-5 score with other disease measures in patients with RA are shown in [Table 2].
|Figure 2 Correlation between Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5) and Disease Activity Score-28 (DAS28).|
Click here to view
|Figure 3 Correlation between Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5) and Quality of Life–Rheumatoid Arthritis (QOLRA) scale.|
Click here to view
|Table 2 Correlation between the Rheumatoid Arthritis Disease Activity Index-5 score and different disease measures in patients with rheumatoid arthritis|
Click here to view
| Discussion|| |
Since many years, the measurement of disease activity in RA has been done by DAS28, which is measured by assessing TJC28 (range: 0–28), SJC28 (range: 0–28), ESR, and general health on visual analog scale (0–100 mm) . However, the formula to calculate the DAS28 score is complicated, requiring the use of a calculator or computer program .
Patient self-report questionnaires provide an easily implemented approach for quantitative assessment of patients with RA in usual care settings , but published reports indicate that they are used infrequently in clinical practice . Questionnaire scores distinguish active from control treatments in clinical trials at similar levels to SJC and TJC or laboratory tests .
The study was aimed to assess the disease activity in patients with RA using RADAI-5 score and to find its correlation with DAS28, quality of life, pain, and functional status.
RADAI-5 is a self-administered tool that comprises only five patient-reported measures, thus supporting the suggestion of Pincus et al. . The RADAI-5 does not require any physician’s intervention, laboratory parameter, biochemical parameter, or radiological investigation for assessment of disease activity. The variables used in RADAI-5 are easily available at a point of care in the clinical setting assessed by patients themselves, which in turn can produce more consistency in timing and completeness of disease measurement .
In the present study, RADAI-5 score of patients with RA indicated moderate disease activity. Overall, 17.5% of patients were in remission, 10% had mild, 47.5% had moderate, and 25% had high disease activity. These rates were 15, 5, 47.5, and 32.5%, respectively, according to DAS28. Sunar et al.  compared the results of RADAI-5 with DAS28 and showed similar data.
RADAI-5 score in the current study was strongly correlated with DAS28 (r=0.9, P<0.001). RADAI-5 has proven to be in line with more time-consuming tools such as DAS28 and Clinical Disease Activity Index ,,,.
Health-Related Quality of Life (HRQL) refers to the effect of disease and treatment on the individual’s welfare. Patients diagnosed as having RA have significant decreases in HRQL, resulting from pain, impaired physical function, and fatigue . In the present study, English version of the QOLRA scale was used to assess HRQL , and a significant correlation between disease activity and quality of life scale (QOLRA scale) was found. Similarly, Cadena et al.  conducted a study among 79 patients with RA in Colombia and they evaluated quality of life by using the same scale. They demonstrated that RA activity significantly influenced quality of life. Similarly, this finding was confirmed in previous studies by Sunar et al. , Prajs et al. , and Houssien et al. .
Disease activity was significantly correlated with pain scale which reflect patient pain perception (r=0.4, P=0.02). A similar relationship was previously shown in the study of Sunar et al. .
Several studies have reported the relationship between functional status and disease activity in RA ,,. In the present study, a statistically significant correlation between disease activity and functional status was found (r=0.6, P<0.001).
In the present study, disease, RADAI‑5 was found to be significantly correlated with morning stiffness duration, RAI, TJC, and SJC (r=0.3, P=0.03; r=0.8, P<0.001; r=0.9, P<0.001; and r=0.7, P<0.001, respectively). In previous studies ,, RADAI‑5 was found to be significantly correlated with TJC and SJC, but no studies showed its correlations with morning stiffness or RAI.
The current study proved a significant correlation of RADAI-5 with ESR and rheumatoid factor positivity (r=0.6, P<0.001 and r=0.4, P=0.008, respectively). In concordance with this finding, Pincus et al.  reported significant correlations of self-reported questionnaire scores with data from laboratory tests, traditional joint counts, radiographs, as well as physical measures of functional status. However, several studies reported no or relatively low correlations of patient questionnaires with laboratory determinants of disease activity such as ESR or CRP ,,.
Finally, self-report questionnaires, such as the RADAI-5, have been shown to be capable of substituting physician-derived DAS, which were developed primarily for research purposes .
| Conclusion|| |
RADAI-5 is a simple and low-cost self-report questionnaire that reflects patients’ perception of signs and symptoms. The correlations of RADAI-5 with DAS28, quality of life, pain score, and functional status reflect its value in the assessment of disease activity in patients with RA. Further longitudinal studies are recommended to test both RADAI-5 and DAS28 for sensitivity and specificity in early detected mild cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Welsing PM, Landewe RB, van Riel PL, Boers M, van Gestel AM, van der Linden S et al.
The relationship between disease activity and radiologic progression in patients with rheumatoid arthritis: a longitudinal analysis. Arthritis Rheum 2004; 50:2082–2093.
Klareskog L, van der Heijde D, de Jager JP, Gough A, Kalden J, Malaise M et al.
Therapeutic effect of the combination of etanercept and methotrexate compared with each treatment alone in patients with rheumatoid arthritis: double-blind randomized controlled trial. Lancet 2004; 363:675–681.
Lard LR, Visser H, Speyer I, vander Horst-Bruinsma IE, Zwinderman AH, Breedveld FC et al.
Early versus delayed treatment in patients with recent-onset rheumatoid arthritis: comparison of two cohorts who received different treatment strategies. Am J Med 2001; 111:446–451.
Nell VP, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease- modifying anti-rheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (Oxford) 2004; 43:906–914.
Smolen JS, Sokka T, Pincus T, Breedveld FC. A proposed treatment algorithm for rheumatoid arthritis: aggressive therapy, methotrexate, and quantitative measures. Clin Exp Rheumatol 2003; 21:S209–S210.
Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R et al.
Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomized controlled trial. Lancet 2004; 364:263–269.
Prevoo ML, van’t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995; 38:44–48.
Pincus T, Sokka T. Quantitative clinical assessment in busy rheumatology settings: the value of short patient questionnaires. J Rheumatol 2008; 35:1235–1237.
Leeb BF, Haindl PM, Maktari A, Nothnagl T, Rintelen B. Patient-centered rheumatoid arthritis disease activity assessment by a modified RADAI. J Rheumatol 2008; 35:1294–1299.
Singh H, Tanwar VS, Sukhija G, Mathur R, Kaur P. Rheumatoid arthritis disease activity index-5: utility in busy clinical settings. Indian J Rheumatol 2017; 12:72–75.
Leeb BF, Haindl PM, Brezinschek HP, Nothnagl T, Rintelen B. RADAI-5 to monitor rheumatoid arthritis. Clin Exp Rheumatol 2014; 32:S55–S58.
Pincus T, Segurado OG. Most visits of most patients with rheumatoid arthritis to most rheumatologists do not include a formal quantitative joint count. Ann Rheum Dis 2006; 65:820–822.
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd et al.
2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010; 62:2569–2581.
Ritchie DM, Boyle JA, McInnes JM, Jasani MK, Dalakos TG, Grieveson P et al.
Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Q J Med 1968; 37:393–406.
Danao LL, Padilla GV, Johnson DA. An English and Spanish quality of life measure for rheumatoid arthritis. Arthritis Rheum 2001; 45:167–173.
Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983; 17:45–56.
Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980; 23:137–145.
Sunar I, Yilmaz Tasdelen O, Garip Cimen Y, Bodur H. Translation and validation of the Turkish language version of the Rheumatoid Arthritis Disease Activity Index-5. Int J Rheum Dis 2014 Still in print Apr 12. doi: 10.1111/1756-185X.12371. [Epub ahead of print].
Van Gestel AM, Haagsma CJ, van Riel PL. Validation of rheumatoid arthritis improvement criteria that include simplified joint counts. Arthritis Rheum 1998; 41:1845–1850.
Pincus T. Advantages and limitations of quantitative measures to assess rheumatoid arthritis: joint counts, radiographs, laboratory tests, and patient. Bull NYU Hosp Jt Dis 2006; 64:32–39.
Castrejón I, Pincus T. Patient self-report outcomes to guide a treat to target strategy in clinical trials and usual clinical care of rheumatoid arthritis. Clin Exp Rheumatol 2012; 30(Suppl 73):S50–S55.
Wolfe F, Pincus T. Current comment – listening to the patient: a practical guide to self-report questionnaires in clinical care. Arthritis Rheum 1999; 42:1797–1808.
Pincus T, Yazici Y, Bergman MJ. Patient questionnaires in rheumatoid arthritis: advantages and limitations as a quantitative, standardized scientific medical history. Rheum Dis Clin North Am 2009; 35:735–743.
Pincus T, Chung C, Segurado OG, Amara I, Koch GG. An index of patient self‑reported outcomes (PRO index) discriminates effectively between active and control treatment in 4 clinical trials of adalimumab in rheumatoid arthritis. J Rheumatol 2006; 33:2146–2152.
Sunar I, Garip Y, Yilmaz Ö, Bodur H, Ataman S. Disease Activity (Rheumatoid Arthritis Disease Activity Index-5) in patients with rheumatoid arthritis and its association with quality of life, pain, fatigue, and functional and psychological status. Arch Rheumatol 2015; 30:144–149.
Mili F, Helmick CG, Moriarty DG. Health related quality of life among adults reporting arthritis: analysis of data from the Behavioral Risk Factor Surveillance System, US, 1996–99. J Rheumatol 2003; 30:160–166.
Cadena J, Vinaccia S, Pérez A, Rico MI, Hinojosa R, Anaya JM. The impact of disease activity on the quality of life, mental health status, and family dysfunction in colombian patients with rheumatoid arthritis. J Clin Rheumatol 2003; 9:142–150.
Prajs K, Flicinski J, Brzosko I, Przepiera-Bedzak H, Ostanek L, Brzosko M. Quality of life and activity of disease in patients with rheumatoid arthritis. Ann Acad Med Stetin 2006; 52:39–43.
Houssien DA, McKenna SP, Scott DL. The Nottingham Health Profile as a measure of disease activity and outcome in rheumatoid arthritis. Br J Rheumatol 1997; 36:69–73.
Molenaar ET, Voskuyl AE, Dijkmans BA. Functional disability in relation to radiological damage and disease activity in patients with rheumatoid arthritis in remission. J Rheumatol 2002; 29:267–270.
Drossaers-Bakker KW, de Buck M, van Zeben D, Zwinderman AH, Breedveld FC, Hazes JMW. Long-term course and outcome of functional capacity in rheumatoid arthritis. Arthritis Rheum 1999; 42:1854–1860.
Pincus T, Callahan LF, Brooks RH, Fuchs HA, Olsen NJ, Kaye JJ. Self-report questionnaire scores in rheumatoid arthritis compared with traditional physical, radiographic, and laboratory measures. Ann Intern Med 1989; 110:259–266.
Riemsma RP, Taal E, Rasker JJ, Houtman PM, van Paassen HC, Wiegman O. Evaluation of a Dutch version of the AIMS2 for patients with rheumatoid arthritis. Br J Rheumatol 1996; 35:755–760.
Stucki G, Liang MH, Stucki S, Brühlmann P, Michel BA. A self-administered rheumatoid arthritis disease activity index (RADAI) for epidemiologic research. Arthritis Rheum 1995; 38:795–798.
Pincus T, Bergman MJ, Yazici Y, Hines P, Raghupathi K, Maclean R. An index of only patient-reported outcome measures, routine assessment of patient index data 3 (RAPID3), in two abatacept clinical trials: similar results to disease activity score (DAS28) and other RAPID indices that include physician-reported measures. Rheumatology 2008; 47:345–349.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]