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DAS28-ESR

Disease Activity Score in 28 joints with ESR — rheumatoid arthritis

Sources last checked: 2026-10-13

DAS28-ESR

Disease Activity Score in 28 joints with ESR — rheumatoid arthritis

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ESR rises with age, anaemia and hypergammaglobulinaemia, and the patient global assessment can keep DAS28 above remission without active synovitis. The 28-joint count omits ankles and feet.

Source: Prevoo ML, van 't Hof MA, Kuper HH, et al. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38(1):44-48.Open

Interpretation

< 2.6 — remissionDAS28 remission threshold.
2.6 to < 3.2 — low disease activityNamed by the treat-to-target recommendations (Smolen 2016) as an acceptable target where remission is not achievable.
3.2 to ≤ 5.1 — moderate disease activityAbove the treat-to-target goal; the T2T recommendations (Smolen 2016) provide for therapy adjustment when the target is not reached.
> 5.1 — high disease activityAbove the treat-to-target goal; the T2T recommendations (Smolen 2016) provide for therapy adjustment when the target is not reached.

What is the DAS28-ESR?

The DAS28 combines the tender and swollen joint counts in 28 joints, the erythrocyte sedimentation rate and the patient's global assessment into a continuous disease-activity score for rheumatoid arthritis. It was developed and validated in Nijmegen by Prevoo and colleagues in 1995 as a 28-joint version of the original DAS. It is the basis of the EULAR response criteria.

When to use it

  • At each visit in rheumatoid arthritis to measure disease activity
  • To apply a treat-to-target strategy (remission or low disease activity)
  • To judge EULAR response after a change in therapy
  • When reimbursement or registries require a DAS28

When not to use it

  • In other arthritides (psoriatic arthritis, spondyloarthritis) — use their own instruments
  • When ESR is clearly driven by something else (pregnancy, anaemia, paraprotein, infection)

How it is calculated

DAS28-ESR = 0.56·√TJC28 + 0.28·√SJC28 + 0.70·ln(ESR) + 0.014·GH ESR in mm/h; GH = patient global assessment on a 0–100 mm VAS.

Clinical pearls and limitations

  • ESR rises with age, anaemia and hypergammaglobulinaemia, and the patient global assessment can keep DAS28 above remission without active synovitis. The 28-joint count omits ankles and feet.
  • EULAR response: improvement > 1.2 to a DAS28 ≤ 3.2 is a good response; ≤ 0.6 is no response; everything in between is moderate (except > 0.6–1.2 ending above 5.1 = no response).
  • DAS28 < 2.6 can coexist with several swollen joints — CDAI/SDAI or Boolean remission are stricter.
  • Feet and ankles are not part of the 28-joint count, so disease activity there is not captured by the score.
  • The patient global (0–100 mm) is weighted 0.014, so it can keep the score above remission on its own.

Frequently asked questions

What DAS28 means remission?

Below 2.6. Low disease activity is 2.6 to below 3.2, moderate 3.2–5.1, high above 5.1.

What is a EULAR good response?

An improvement of more than 1.2 together with a current DAS28 of 3.2 or less.

Which 28 joints are counted?

Shoulders, elbows, wrists, MCP 1–5, PIP 1–5 (thumb IP included) on both sides, and both knees.

Evidence and guidelines

  1. Primary source: Prevoo ML, van 't Hof MA, Kuper HH, et al. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38(1):44-48.
  2. DAS-score.nl (Radboud University Nijmegen): How to calculate the DAS28; alternative validated formulae; EULAR response criteria.
  3. van Gestel AM et al. Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis. Arthritis Rheum 1996;39(1):34-40.
  4. England BR et al. 2019 Update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures. Arthritis Care Res 2019;71(12):1540-1555.
  5. Smolen JS et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 2016;75(1):3-15.

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