Normal Erythrocyte Sedimentation Rate (ESR)
ESR values are typically considered normal when they are below 20 mm/h in men and below 30 mm/h in women, though these thresholds increase with age and can reach 35-40 mm/h in healthy elderly persons. 1, 2
Standard Reference Ranges by Population
- Men: ESR <20 mm/h is considered normal 1
- Women: ESR <30 mm/h is considered normal, with women having inherently higher baseline values than men 1
- Elderly patients: ESR may be as high as 35-40 mm/h in healthy aged persons without indicating disease 2
Clinical Context for Interpreting ESR Values
Mild Elevation (20-50 mm/h)
- Values in this range are considered mildly elevated and warrant clinical correlation 1
- In ulcerative colitis disease activity assessment, ESR <20 mm/h indicates mild disease 3
- ESR between 20-30 mm/h in ulcerative colitis suggests moderate disease activity 3
Moderate Elevation (50-100 mm/h)
- ESR >30 mm/h indicates severe disease activity in ulcerative colitis 3
- ESR >40 mm/h has 93.2% sensitivity for giant cell arteritis with a negative likelihood ratio of 0.18 1, 4
- ESR >50 mm/h has 87.5% sensitivity for giant cell arteritis 4
- Moderate elevation (50-100 mm/h) is more likely to indicate significant underlying disease 1
Marked Elevation (>100 mm/h)
- ESR >100 mm/h has the highest specificity (92.2%) for giant cell arteritis with a positive likelihood ratio of 3.11 1, 4
- In Kawasaki disease, ESR commonly reaches levels of at least 100 mm/h 1
- ESR ≥70 mm/h has 81% sensitivity and 80% specificity for diagnosing osteomyelitis in diabetes-related foot infections 1
Important Caveats Affecting ESR Interpretation
Factors that artificially elevate ESR independent of disease:
- Anemia can increase ESR values 1, 4
- Azotemia (elevated blood urea nitrogen) elevates ESR 1, 4
- Female gender naturally produces higher baseline values 1, 4
- Advanced age increases normal ESR thresholds 2
Critical limitations:
- ESR is unreliable as a screening test in asymptomatic persons 5
- Approximately 25% of elderly patients with significant disease (both malignant and nonmalignant) have ESR below 20 mm/h 2
- ESR is often normal in patients with cancer, infection, and connective tissue disease, making it unsuitable for excluding these diseases 5
- An unexplained increase in ESR is generally transitory and seldom due to serious disease 5
Clinical Applications Where ESR is Most Useful
ESR has proven diagnostic and monitoring value in:
- Diagnosing temporal arteritis (giant cell arteritis) and monitoring treatment response 5
- Monitoring disease activity in polymyalgia rheumatica, where ESR >40 mm/h is associated with higher relapse rates 1
- Assessing disease activity in inflammatory arthritis using composite measures like DAS28-ESR 1
- Monitoring chronic inflammatory conditions with measurements every 1-3 months during active disease, then every 3-6 months in remission 1