After some thought as I weighed in the balance—three tender and swollen joints versus a DAS of 2.80—I decided to increase the methotrexate to 17.5 milligrams a week. That certainly was not a bold move, but I felt better knowing that I had at least done something that could quell the troubles that may have been brewing in three of the Mr. Jones’ joints.
I like the DAS because I have several years experience with its use and, frankly, I like the convenience of the website. I know that the DAS did not make the grade in the deliberations of the ACR/European League Against Rheumatism committee that has defined remission in RA. Nevertheless, as T2T becomes more of a standard, numerous issues will arise about any of the metrics that are used in research or clinical practice in define disease states. Whether it is the DAS28, DAS44, SDAI, CDAI, HAQ, or RAPID3, uncertainty and ambiguities will abound, starting with the extent of synovitis that is still consistent with a state of remission. We will have to contend with the meaning of joint tenderness and swelling and, trust me, answering the question, “How active has your arthritis been in the last seven days?” is not easy, especially when symptoms fluctuate wildly (“I don’t hurt unless I stand”), and the patient does not appreciate or accept the distinction between pain and inflammation.
I am happy that T2T is here to stay, even if an occasional value looks bizarre and will stymie me as I decide whether to increase or decrease an agent or add another therapy. Fortunately, rheumatologists have an increasingly large armamentarium of effective agents to allow target practice (pun intended).
Nevertheless, I have my worries and doubts about relying on existing outcome measures to make important decisions on treatment. Even if the DAS or CDAI provide values with two numbers after the decimal point, how solid—or, to use a popular word, robust—are those values?
Dear reader, I have a question that has been nagging at me since that day in clinic, and I would like your advice. In increasing Mr. Jones’ methotrexate, did I make the right call? In other words, was I on target? the rheumatologist
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
