The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a new composite index to assess disease

activity in Ankylosing Spondylitis (AS)1. It combines five disease activity variables with only partial
overlap, resulting in one single score with better truth (validity), enhanced discriminative capacity and
improved sensitivity to change as compared to single-item variables.(1,2)

Table 1. The two ASDAS formulas: ASDAS-CRP (preferred) and ASDAS-ESR (alternative).

0.12 x Back Pain + 0.06 x Duration of Morning Stiffness + 0.11 x Patient

ASDAS-CRP
Global + 0.07 x Peripheral Pain/Swelling + 0.58 x Ln(CRP+1)
0.08 x Back Pain + 0.07 x Duration of Morning Stiffness + 0.11 x Patient
ASDAS-ESR
Global + 0.09 x Peripheral Pain/Swelling + 0.29 x (ESR)

ASDAS, Ankylosing Spondylitis Disease Activity Score; (ESR), square root of the erythrocyte
sedimentation rate (mm/h); Ln(CRP+1), natural logarithm of the C-reactive protein (mg/L) +
1. Back pain, patient global, duration of morning stiffness and peripheral pain/swelling are
all assessed on a visual analogue scale (from 0 to 10cm) or on a numerical rating scale (from
0 to 10).
Back pain, BASDAI question 2: "How would you describe the overall level of AS neck, back or
hip pain you have had?".
Duration of morning stiffness, BASDAI question 6: "How long does your morning stiffness
last from the time you wake up?".
Patient global: "How active was your spondylitis on average during the last week?"
Peripheral pain/swelling, BASDAI question 3: "How would you describe the overall level of
pain/swelling in joints other than neck, back or hips you have had?"

The Assessment of SpondyloArthritis international Society (ASAS) membership has selected the ASDAS
containing C-reactive protein (CRP, mg/l) as acute phase reactant as the preferred version, and the one
with erythrocyte sedimentation rate (ESR, mm/hr) as the alternative version. Apart from the value of
CRP or ESR, the four additional self-reported items included in this index are back pain (0-10cm, visual
analogue scale [VAS] or 0-10, numerical rating scale [NRS]), duration of morning stiffness (VAS/NRS),
peripheral pain/swelling (VAS/NRS) and patient global assessment of disease activity (VAS/NRS) (table
1).(1,2)

The next step to consolidate the ASDAS as an instrument to measure disease activity in AS was the
development of cut-offs for disease activity states and improvement scores. During the 2010 ASAS
workshop in Berlin, Germany, cut-offs for the ASDAS were proposed, and cross-validation studies were
presented. The methodology and the results were debated by ASAS members and four disease activity
states were chosen by consensus: "inactive disease", "moderate disease activity", "high disease activity"
and "very high disease activity".

The 3 cut-offs selected to separate these states (figure 1) were: <1.3 between "inactive disease" and
"moderate disease activity", <2.1 between "moderate disease activity" and "high disease activity", and
>3.5 between "high disease activity" and "very high disease activity".

Selected cut-offs for improvement scores (figure 2) were: a change 1.1 units for "clinically important
improvement" and a change 2.0 units for "major improvement".(3)

Figure 1. Selected cut-offs for disease activity states.

Figure 2. Selected cut-offs for improvement scores.

At the Outcome Measures in Rheumatology (OMERACT) 10 conference, in Kota Kinabalu, Malaysia, the
ASDAS disease activity states and response criteria also obtained the endorsement from OMERACT.(4)

Using the ASDAS and the newly validated cut-off values, we hope that clinicians can better assess the
effectiveness of treatments and determine whether they are providing clinically meaningful
improvement. The higher discriminatory capacity of the ASDAS compared to classical response criteria in
AS may have important implications in reducing sample size calculation for clinical trials. The ASDAS will
also allow clinicians, investigators, regulators, and patients to continue communicating about treatment
response using the same metric.

1. Total Back Pain

Based on your assessment, please indicate what is the amount of back pain at any time that you
experienced during the last week?

No Most Severe
Pain 0 1 2 3 4 5 6 7 8 9 10 Pain

2. How long does your morning stiffness last from the time you wake up?

0 hours 2 or more hours

0 1 2 3 4 5 6 7 8 9 10
1 hour
3. Global Disease Activity
Please tick a box to indicate your overall assessment of your disease activity during the last week.

None Severe
0 1 2 3 4 5 6 7 8 9 10

4. How would you describe the overall level of pain/swelling in joints other than neck, back or hips you
have had?

None Very Severe

0 1 2 3 4 5 6 7 8 9 10

The BASDAI consists of a one through 10 scale (one being no problem and 10 being the worst problem)
which is used to answer 6 questions pertaining to the 5 major symptoms of AS:
Fatigue
Spinal pain
Joint pain / swelling
Areas of localized tenderness (also called enthesitis, or inflammation of tendons and ligaments)
Morning stiffness duration
Morning stiffness severity
To give each symptom equal weighting, the mean (average) of the two scores relating to morning
stiffness is taken. The resulting 0 to 50 score is divided by 5 to give a final 0 10 BASDAI score. Scores of
4 or greater suggest suboptimal control of disease, and patients with scores of 4 or greater are usually
good candidates for either a change in their medical therapy or for enrollment in clinical trials evaluating
new drug therapies directed at Ankylosing Spondylitis. More information for physicians regarding tools
to measure AS are presented.

When evaluated using strict clinical paramaters, the BASDAI was validated:
BASDAI is a quick and simple index (taking between 30 secs and 2 mins to complete)
BASDAI demonstrated statistically significant (p<0.001) reliability.
BASDAI encorporates a reasonable scale. The individual symptoms and the index as a whole
demonstrated good score distribution, using 95% of the scale.
BASDAI demonstrates a sensitivity to change within a short period of time. Following a 3 week
physiotherapy course, the BASDAI showed a significant (p=0.009) 16.4% score improvement.