A systematic review of the effectiveness of adalimumab

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Appendix 1
Disease Activity Score (DAS)
Original DAS
DAS = 0.54(√ ———
RAI) + 0.065(total number of
swollen joints out of 44) + 0.33(ln ESR)
+ 0.0072 (patient general health score
where 0=best, 100=worst)
where RAI refers to a graded score of joint
tenderness for 53 joints, known as the Ritchie
Articular Index.
DAS based on 28 joint evaluations
DAS 28-4 = 0.56(√ ———
TJC28 — ) + 0.28(√ ———
SJC28 — ) +
0.7ln(ESR) + 0.014 (patient
general health score where 0=best,
100=worst)
where TJC is tender joint count and SJC is swollen
joint count. Where scores for general health are
not available, or not measured, the following
formula is used:
DAS 28-3 = [0.56(√ ———
TJC28 — ) + 0.28(√ ———
SJC28 — ) +
0.7ln(ESR)]1.08 + 0.16
Radiographic assessment
methods 209
Sharp score
The simplified Sharp system, 210 which evaluates
hand and wrist images, assesses 17 areas for
erosions and 18 areas for joint space narrowing.
Each joint is scored on a six-point scale as follows:
0 = no erosion; 1 = discrete erosion; 2 = two
separate quadrants with erosions or 20–40% joint
involvement; 3 = 3 separate quadrants with
erosions or 41–60% joint involvement; 4 = all four
quadrants with joint erosion or 61–80% joint
involvement; and 5 = extensive destruction with
over 80% joint involvement. The range of erosion
scores for a patient with two hands and wrists is
0–170. For joint space narrowing each joint is
scored using a five-point scale as follows: 0 = no
narrowing; 1 = up to 25% narrowing; 2 = 26–65%
narrowing; 3 = 66–99% narrowing; and 4 =
complete narrowing. The range for joint space
narrowing is therefore 0–144. This gives a total
joint score in the range 0–314.
Van der Heijde modified Sharp score
In this case 16 joints are assessed in each hand
and wrist and six joints in each foot. Erosions are
scored 0–5 and depending on the affected surface
area and 0–10 in the feet, yielding possible
erosion scores of 0–160 for hands/wrists and 0–120
for feet (total 0–280). Joint space narrowing is
assessed in 15 joints for each hand/wrist and six
joints in each foot on a scale of 0–4. The range of
possible joint space narrowing scores is in the
range 0–168. This yields a possible total score in
the range 0–448. 211
Larsen score
In this method standard films are used to classify
each joint into one of six possible categories (0 =
normal, 5 = severely damaged). Any joint may be
scored, but the focus is on hands and feet. In the
hands each proximal interphalangeal joint and
each metacarpophalangeal joint scores 0–5; each
wrist joint scores 0–25 (the basic score is
multiplied by 5): this gives a maximum score of
150 for two hands and wrists. In the feet each
metatarsophalangeal joint is scored 0–5, giving a
total score of 50 for two feet. This yields a possible
total score in the range 0–200.
Scott-modified Larsen 212
Scott and colleagues suggested minor
modifications to the scale to improve correlation
between scorers. It was proposed that grade 1
included erosions and cysts of less than 1 mm
diameter and grade 2 included one or more
erosions of more than 1 mm diameter.