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Fibromyalgia Effect on DAS28 — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisFibromyalgia Effect on DAS28SCE Rheumatology

A 50-year-old woman with seropositive rheumatoid arthritis and established fibromyalgia is taking stable methotrexate therapy. She reports widespread pain. Her DAS28-ESR is 5.2, comprising a tender joint count of 14/28, swollen joint count of 1/28, ESR of 10 mm/hour and patient global assessment of 80 mm. Which interpretation best describes the impact of fibromyalgia on this DAS28 assessment?

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Correct answer: D — Fibromyalgia can inflate DAS28 through the tender joint count and patient global assessment, overestimating inflammatory activity

Coexisting fibromyalgia can raise the DAS28 without a corresponding increase in synovial inflammation. It predominantly increases pain-sensitive components, particularly the tender joint count and patient global assessment. Here, the marked discordance between 14 tender joints and only one swollen joint, together with a normal ESR, suggests that the DAS28 of 5.2 may overestimate inflammatory RA activity. Fibromyalgia does not primarily raise ESR, making A incorrect, and a normal ESR does not remove its effect on the composite score, excluding B. Option B is false because tender joint count and patient global assessment are included in DAS28. Fibromyalgia does not intrinsically lower DAS28, excluding E. Clinical examination, inflammatory markers and, where uncertainty persists, imaging should be integrated before escalating DMARD therapy.

Reference: Das D, Choy E. Non-inflammatory pain in inflammatory arthritis. Rheumatology (Oxford). 2023;62(7):2360-2365. https://pubmed.ncbi.nlm.nih.gov/36478185/