Clinical disease activity index versus disease activity score (28 joints) for assessment of disease activity in obese patients of rheumatoid arthritis


  • Sarthak Saxena Department of Medicine, ABVIMS, Dr RML Hospital, New Delhi, Delhi, India
  • B. K. Kundu Department of Medicine, ABVIMS, Dr RML Hospital, New Delhi, Delhi, India



CDAI, DAS28, Disease activity assessment, Obesity, Rheumatoid arthritis


Background: Measurement of disease activity by Disease Activity Score 28 joints -Erythrocyte Sedimentation Rate (DAS28-ESR), Disease Activity Score (28 joints)-C-Reactive Protein (DAS28-CRP), and Clinical Disease Activity Index (CDAI) has become an integral part of management of Rheumatoid Arthritis (RA), by ‘Treatment to Target’ approach. With the exception of CDAI, the other two use inflammatory markers ESR and CRP to measure disease activity. Obesity is also known to increase inflammatory markers like CRP. We undertake this study to examine if obesity confounds the disease activity measurement in RA leading to overestimation of disease activity.

Methods: A cross-sectional observation study was conducted on one hundred patients of RA (40 obese and 60 non obese) in remission or low disease activity as defined by CDAI. They were divided into obese and non-obese groups based on Indian standards (BMI>25kg/m2). ESR and CRP were measured in both the groups. DAS28-ESR and DAS28-CRP were calculated and compared using relevant statistical tests.

Results: DAS28-ESR and DAS-28-CRP scores were significantly higher in the obese subjects, despite both groups having comparable CDAI scores. Similar findings were also observed with inflammatory markers ESR and CRP, both being higher in obese patients.

Conclusions: We conclude that indices incorporating inflammatory markers, like DAS28 overestimate disease activity in obese RA patients. Treatment decisions regarding escalation or addition of DMARDs should be taken after considering the same. CDAI appears to be better suited for disease activity measurements in obese RA patients as compared to DAS 28.


Malaviya AN, Kapoor SK, Singh RR, Kumar A, Pande I. Prevalence of rheumatoid arthritis in the adult Indian population. Rheumatol Int. 1993;13(4):131-4.

Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, et al. Rheumatoid arthritis. Nat Rev Dis Primers. 2018;4(1):18001.

Rintelen B, Sautner J, Haindl P, Andel I, Maktari A, Leeb B. Comparison of three rheumatoid arthritis disease activity scores in clinical routine. Scand J Rheumatol. 2009;38(5):336-41.

Aronson D, Bartha P, Zinder O, Kerner A, Markiewicz W, Avizohar O, et al. Obesity is the major determinant of elevated C-reactive protein in subjects with the metabolic syndrome. Int J Obes. 2004;28(5):674-9.

Visser M. Elevated C-reactive protein levels in overweight and obese adults. JAMA. 1999;282(22):2131.

Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Associat Physic India. 2009;57(2):163-70.

Dessein PH, Norton GR, Woodiwiss AJ, Joffe BI, Solomon A. Independent role of conventional cardiovascular risk factors as predictors of C-reactive protein concentrations in rheumatoid arthritis. J Rheumatol. 2007;34(4):681-8.

Giles JT, Ling SM, Ferrucci L, Bartlett SJ, Andersen RE, Towns M, et al. Abnormal body composition phenotypes in older rheumatoid arthritis patients: Association with disease characteristics and pharmacotherapies. Arthr Rheu. 2008;59(6):807-15.

Sharma A, Kumar A, Jha A, Agarwal A, Misra A. The impact of obesity on inflammatory markers used in the assessment of disease activity in rheumatoid arthritis-a cross-sectional study. Reumatol. 2020;58(1):9-14.

Kvein TK. Epidemiological aspects of rheumatoid arthritis: the sex ratio. Ann N Y Acad Sci. 2006;1069(1):212-22.

Qasim AN, Budharaju V, Mehta NN, St Clair C, Farouk S, Braunstein S, et al. Gender differences in the association of C-reactive protein with coronary artery calcium in Type-2 diabetes. Clin Endocrinol (Oxf). 2011;74(1):44-50.

Abuhelwa AY, Hopkins AM, Sorich MJ, Proudman S, Foster DJR, Wiese MD. Association between obesity and remission in rheumatoid arthritis patients treated with disease-modifying anti-rheumatic drugs. Sci Rep. 2020;10(1).

Schäfer M, Meißner Y, Kekow J, Berger S, Remstedt S, Manger B, et al. Obesity reduces the real-world effectiveness of cytokine-targeted but not cell-targeted disease-modifying agents in rheumatoid arthritis. Rheumatol (UK). 2020;59(8):1916-26.






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