Will Rheumatoid Arthritis (RA) bloodwork, specifically inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), decrease if the disease is getting better?

From the Guidelines

Yes, bloodwork for rheumatoid arthritis (RA) typically shows improvement when the disease is getting better, with inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) often decreasing as inflammation subsides with effective treatment. According to the most recent and highest quality study, 1, effective treatments like disease-modifying antirheumatic drugs (DMARDs), biologics, and JAK inhibitors work by reducing inflammation, which is then reflected in improved bloodwork values over time.

Key Points to Consider

• Inflammatory markers such as CRP and ESR are commonly used to assess disease activity in RA patients 2, 3
• These markers often decrease with effective treatment, reflecting reduced inflammation and improved disease control 1
• However, some patients may experience a disconnect between their bloodwork and symptoms, highlighting the importance of regular monitoring of both bloodwork and clinical symptoms 4, 2
• The choice of disease activity measure may be influenced by consideration of co-morbidities, patient factors, and drug-related risks, with some measures being more suitable for certain patient populations 2, 3

Disease Activity Measures

• Several validated composite measures of disease activity are available, including the Disease Activity Score (DAS), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) 2, 3
• These measures often include a combination of patient-reported outcomes, provider assessments, and laboratory tests, such as CRP and ESR 2, 3
• The choice of measure may depend on the specific patient population, treatment goals, and clinical setting 2, 3

Treatment Implications

• Effective treatment of RA often involves a combination of medications, including DMARDs, biologics, and JAK inhibitors 1
• Regular monitoring of disease activity and adjustment of treatment as needed is crucial to achieving optimal outcomes and minimizing disease progression 4, 2
• Patient education and involvement in treatment decisions are also essential to ensuring effective management of RA and improving patient outcomes 4, 2

From the Research

Relationship Between Inflammatory Markers and Disease Activity in Rheumatoid Arthritis

• The study 5 found that CRP has a moderately strong relationship with disease activity, but there are significant pitfalls in the use of this biomarker in RA.
• The albumin to fibrinogen ratio (AFR) and C-reactive protein to albumin ratio (CAR) have emerged as useful biomarkers to predict systemic inflammation, with AFR being lower in patients with active disease and CAR being higher in patients with active disease 6.
• A positive correlation was observed between DAS 28-ESR score and CAR, while the correlation between DAS 28-ESR and AFR was negative 6.
• Pain intensity is associated with disease activity in general, and particularly with patient global assessments, across all patient groups 7.

Decrease in Inflammatory Markers with Improvement in Disease Activity

• The study 8 found that attaining remission is highly specific for attaining low disability and normal HRQoL, although many patients with more active disease also have good function and HRQoL.
• The study 9 found that RA patients who were partial responders to long-term MTX or etanercept monotherapy obtained a higher efficacy with combination therapy, with improvements in DAS remission rates and low disease activity.
• The study 6 found that AFR was related to decreased risk of RA disease activity, suggesting that a decrease in inflammatory markers may be associated with an improvement in disease activity.
• The study 7 found that reducing disease activity is crucial for reducing pain intensity in RA, with strong temporal relationships between changes in disease activity and pain intensity.

Inflammatory Markers as Indicators of Disease Activity

• ESR and CRP are commonly used inflammatory markers to assess disease activity in RA 8, 5, 6.
• The study 5 found that histological evidence of inflammation in the synovium was present in 49.4% of patients with normal CRP, highlighting the limitations of using CRP as a sole indicator of disease activity.
• The study 6 found that AFR and CAR are two novel inflammatory markers for monitoring disease activity in patients with RA, with AFR being lower in patients with active disease and CAR being higher in patients with active disease.