Vol. 11, Issue 1 (2025)

Background: We conducted a systematic review of current guidelines for using the Disease Activity Score for 28 joints (DAS28) to guide the initiation of multidrug therapy in the treatment of rheumatoid arthritis (RA). The review aimed to assess the scope and consistency of these guidelines, highlight variations in recommendations, and identify areas of divergence or consensus in clinical practice.
Methods: Medline and Embase databases were searched from January 2000 to January 2023 using terms related to 'DAS28,' 'multidrug therapy,' and 'rheumatoid arthritis,' along with publications from relevant national and international bodies. Guidelines published in English that addressed DAS28 scoring as a criterion for initiating multidrug therapy were included. Narrative synthesis was performed to accommodate heterogeneity among the guidelines.
Results: Of 482 articles identified, 19 met the inclusion criteria. Most guidelines were developed by rheumatologists, with limited involvement of patient representatives and multidisciplinary experts. All guidelines endorsed DAS28 as a key tool for assessing disease activity, recommending its use to classify patients into high, moderate, or low disease activity states. Fifteen guidelines suggested initiating multidrug therapy in patients with moderate to high disease activity as defined by DAS28, while four also considered additional clinical or patient-specific factors. Methotrexate was commonly included as a first-line component of multidrug regimens. Sixteen guidelines emphasized the need for regular DAS28 monitoring to guide treatment adjustments, while three provided specific DAS28 thresholds for modifying or tapering therapy. Guidelines varied on the preferred combination of conventional DMARDs, with fewer offering detailed recommendations on integrating biologics or targeted therapies based on DAS28 scores.
Conclusions: DAS28 is widely endorsed as a pivotal metric for initiating and monitoring multidrug therapy in RA. Key consensus points include using DAS28 to assess disease activity and initiate aggressive therapy in moderate to high disease states. Variability exists in specific thresholds and preferred drug combinations, underscoring the need for more standardized, evidence-based recommendations.