Annals of Clinical & Laboratory Science, vol. 34, no.

4, 2004 423

Associations between Acute Phase Reactant Levels and Disease

Activity Score (DAS28) in Patients with Rheumatoid Arthritis

Kadir Yildirim, Saliha Karatay, Meltem Alkan Melikoglu, Gurhan Gureser, Mahir Ugur, Kazm Senel
Department of Physical Medicine and Rehabilitation, Atatrk University Medical School, Erzurum, Turkey

Abstract. Serum levels of acute phase reactants (APR) were measured in patients with rheumatoid arthritis
(RA) and the correlations of these parameters with the disease activity score (DAS28) were investigated.
The study included 47 patients with RA and 50 healthy controls. Laboratory tests included erythrocyte
sedimentation rate (ESR), serum C-reactive protein (CRP), haptoglobin (Hp), ferritin, and plasma fibrinogen.
Disease activity was assessed using the DAS28 score. The means ( SD) of ESR, CRP, Hp, ferritin, and
fibrinogen levels were respectively 36.0 23.5 mm/hr, 2.4 1.9 mg/dl, 121.3 34.2 mg/dl, 67.7 36.2
ng/ml, and 371.2 96.0 mg/dl in the patients with RA, vs 16.4 11.3 mm/hr, 0.4 0.3 mg/dl, 104.0
35.3 mg/dl, 50.9 23 ng/ml, and 332.2 58.5 mg/dl in the controls. All of the APR levels were significantly
higher in patients vs controls (p <0.001 for ESR and CRP; p <0.05 for Hp, ferritin, and fibrinogen). There
were significant correlations between serum APR levels and disease activity based on DAS28 score in RA
patients (for CRP, r = 0.650, p <0.01; for Hp, r = 0.331, p <0.05; for ferritin, r = 0.299, p <0.05; for
fibrinogen, r = 0.373, p <0.01). This study indicates that serum CRP, among the various ARP tests, is the
most useful biochemical marker for evaluating the disease activity of patients with RA. (received 20 August 2004;
accepted 25 August 2004).

Keywords: rheumatoid arthritis, DAS28 score, acute phase reactants, C-reactive protein

Introduction insights into the activity of this disease and to assess

Rheumatoid arthritis (RA) is a chronic systemic
disease, usually manifesting as inflammation of
multiple joints. It is characterized by a number of
extra-articular manifestations, including rheumatoid
nodules, vasculitis, heart or lung disease, anemia,
and peripheral neuropathy. Although the cause of
RA is unknown, it is generally considered an
autoimmune disease [1,2]. At present, no single test
of disease activity in RA is effective because RA may
cause various kinds of symptoms and signs.
The acute-phase response to tissue injury and
inflammation is accompanied by a dramatic increase
in hepatic synthesis of plasma proteins known as
acute-phase reactants (APR). Therefore, character-
ization of APR responses in RA is essential to gain
Address correspondence to Kadir Yildirim, M.D., Atatrk
niversitesi Tp Fakltesi Fiziksel Tp ve Rehabilitasyon
Anabilim Dali 25240, Erzurum, Turkey; tel 90 442 236 1212/
1623; fax 90 442 236 1301; e-mail: kadiryildirim88@
hotmail.com.
the degree of inflammation [3,4]. The important
APR include serum C-reactive protein (CRP),
amyloid A (SAA), haptoglobin (Hp), ferritin, and
plasma fibrinogen.
CRP is one of the best indicators of the acute
phase response to inflammation. This serum protein
is synthesized by hepatocytes and is classified as an
acute-phase protein on the basis of its increased
serum concentration during infection and
inflammation [5]. Hp is used for the detection of in
vivo hemolysis and inflammation. The primary
function of Hp is the irreversible binding of free
oxyhemoglobin in serum. This complex is then
removed within minutes by the reticuloendothelial
system. Elevated values are present in chronic and
acute inflammation and in neoplastic diseases [6].
Ferritin is a serum predictor of iron storage.
High levels of serum ferritin have been associated
with malignant disease and tissue damage [7].
Fibrinogen is a glucoprotein with a molecular weight
of 340 kDa. Fibrinogen, while of primary

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 424 Annals of Clinical & Laboratory Science, vol. 34, no. 4, 2004
importance as a coagulation protein, is also an APR
and its plasma concentration is increased in diseases
involving tissue damage or inflammation [8].
The DAS28 score is used extensively to evaluate
disease activity in patients with rheumatoid arthritis
(RA). DAS28 is a composite index that provides
clinicians with a simple and objective assessment of
the patients level of disease activity and progression
[9]. The aim of this study was to investigate the
correlations between DAS28 score and the various
APR levels in RA patients and to determine which
of the acute phase reactants shows the closest
relationship to the disease activity.
Material and Methods
This study involved patients with RA diagnosed
according to the 1987 revised criteria of the
American College of Rheumatology (formerly, the
American Rheumatism Association) [10]. Clinical
assessments included demographic data: age, sex,
weight, and duration of disease. In the patient group
(n = 47), there were 40 women and 7 men (mean
age 45.7 9.5 yr; range 24-66). The mean disease
duration was 10.8 4.4 yr (range 3-24). In the
control group (n = 50), there were 45 women and 5
men (mean age 44.9 8.8 yr, range, 27-63). The
controls were healthy hospital personnel without any
history of inflammatory diseases. No patient was
receiving glucocorticoids or immunosuppressant
drugs, such as cyclosporine or levamisole. At the time
of the study, 27 patients were treated with a comb-
ination of methotrexate and sulfasalazyn; 20 patients
were receiving only methotrexate. All patients were
being treated with nonsteroidal anti-inflammatory
drugs. The patients were allowed to continue their
drug regimens. Patients were excluded if they had
signs or symptoms of severe renal, hepatic, endocrine
(Pagets disease, hyper-thyroidism, hyperpara-
thyroidism), hematological, lymphoproliferative,
and other malignant diseases. The exclusion criteria
for the control group were the same as for the RA
group.
The DAS28 score is the numerical sum of 4
outcome parameters: tender and swollen joint count
(based on a 28-joint assessment), patients global
assessment, visual analogue scale, and ESR value.
423_426 424
The DAS28 score (DAS28/ESR) was calculated
according to Prevoo et al [9].
Blood ESR was determined by the Westergren
method and serum CRP by nephelometry using the
Array Protein System (Beckman Coulter, Inc).
Serum Hp level was assayed with a commercial kit
by a nephelometric method (Beckman Coulter
Image). Serum ferritin level was measured by an
automatic analyzer system (E170 Modular System,
Roche Diagnostics). Plasma fibrinogen level was
determined with a commercial kit using an
autoanalyzer (Dade-Behring Corp).
Statistical analyses of data were performed with
the SPSS program. Laboratory results were given as
mean SD. Differences between groups were
evaluated by the Mann-Whitney U test. Correlation
between variables was assessed by Spearmans rank
correlation coefficient. P values <0.05 were regarded
as significant.
Results
Demographic data for the 47 RA patients and 50
control subjects are listed in Table 1. There were no
significant differences between the 2 groups with
respect to parameters such as age, gender, or body
weight (p >0.05).
Laboratory findings in the RA patients and
healthy controls are listed in Table 2. The mean levels
of ESR, CRP, Hp, ferritin, and fibrinogen in RA
patients were all significantly higher than in healthy
controls (for ESR and CRP, p <0.001; for Hp,
ferritin, and fibrinogen, p <0.05).
Strongly positive correlation was noted between
the DAS28 score and serum CRP level (r = 0.650, p
<0.001) in RA patients (Fig. 1). There were also
significant correlations between the DAS28 score
Table 1. Demographic properties of the patients with RA and
healthy controls (mean SD).
Characteristic RA group Controls p value
Number (M/F) n = 47 (7/40) n = 50 (5/45) ns
Age (yr) 45.7 9.5 44.9 8.8 ns
Body weight (kg) 66.1 7.3 67.3 8.3 ns
Disease duration (yr) 10.8 4.4 - -
ns: not a statistically significant difference.
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 Acute phase reactants and DAS28 in rheumatoid arthritis 425

Table 2. Serum or plasma levels of some acute-phase reactants

in RA patients and healthy controls and the DAS28/EAS score
in RA patients (mean SD)

Parameter RA group Controls p

(n = 47) (n = 50) value

ESR (mm/h) 36.0 23.5 16.411.3 <0.001

CRP (mg/dl) 2.4 1.9 0.40.3 <0.001
Hp (mg/dl) 121.3 34.3 104.035.3 <0.05
Ferritin (ng/ml) 67.7 36.2 50.9 23.8 <0.05
Fibrinogen (mg/dl) 371.2 96.0 332.2 58.8 <0.05
DAS28/ESR score 5.2 1.3 - -

ESR: erythrocyte sedimentation rate; CRP: C-reactive protein;

Hp: haptoglobulin; DAS28/ESR: disease activity score [9].
and other APR levels, such as Hp, ferritin, and
fibrinogen (r = 0.331, p <0.05; r = 0.299, p <0.05;
and r = 0.373, p <0.01, respectively).
Discussion
RA is a chronic disease, but the disease activity is a
fluctuating process, showing great variation even
during the course of one day as well as longer time
periods. Elevated plasma levels of APR develop
during the acute phase response following an
inflammatory stimulus [11].
We performed this study to examine the
correlations between several APR levels (eg, CRP,
Hp, ferritin, fibrinogen) and the DAS28 score,
which serves as an index of disease activity in RA
patients. We observed that CRP, Hp, ferritin, and
fibrinogen levels were all elevated in the RA patients,
compared with control subjects. The APR levels
were all significantly correlated with the DAS28
score. The strongest correlation was between serum
CRP and DAS28 score. The correlation between
DAS28 score and plasma fibrinogen levels was
stronger than the correlations between DAS28 score
and serum Hp or ferritin levels.
Elevated serum CRP, amyloid A protein (SAA),
Hp, ferritin, and plasma fibrinogen levels have all
been associated with inflammatory and infectious
diseases [12]. Several studies have reported strong
associations between these markers of the acute-
phase response and disease activity in patients with
inflammatory diseases [13-16]. CRP belongs to the
Fig. 1. Correlation between DAS28 disease activity score and
serum CRP level in 47 RA patients. The Spearman rank
correlation coefficient (r) was 0.650 (p <0.001).
-globulin family of plasma proteins; although its
physiological functions are unknown, serum levels
of CRP are elevated in a wide variety of acute and
chronic inflammatory conditions [17].
CRP levels are not directly affected by the
commonly used anti-inflammatory drugs, including
steroids; therefore change in CRP probably reflects
a change in the underlying disease [17,18]. In the
present study, among the various APR tests, serum
CRP level was most closely correlated with the
activity of the disease in RA patients. Previous
investigators have also reported positive correlation
between CRP levels and disease activity in RA
patients [13,19]. The results of this study confirm
our previous findings in patients with ankylosing
spondylitis [14].
Serum Hp levels are increased in conditions with
extensive tissue damage, inflammation, or necrosis.
Hp may have an immunosuppressive activity [6,20].
In the present study, serum Hp and ferritin levels in
patients with RA were higher than in the controls
and showed weak correlations with the DAS28 score.
Serum ferritin level is a marker of body iron
stores and may be an indicator of iron deficiency in
patients with chronic inflammation such as RA [21].
The present findings agree with a previous report of
high serum ferritin levels in RA patients compared
to healthy controls [22].
Increased plasma fibrinogen levels occur with
inflammation, during pregnancy, and in women
taking oral contraceptives, as well as in RA patients

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 426 Annals of Clinical & Laboratory Science, vol. 34, no. 4, 2004
[23,24]. None of our RA patients were pregnant or
used oral contraceptives, so their elevated plasma
fibrinogen levels are probably attributable to RA.
In conclusion, of the several APR markers that
were examined in this study, serum CRP level was
the best biochemical indicator of disease activity in
RA patients.
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