INTRODUCTION: The aim of this study was to determine a low disease activity 
threshold--a 28-joint disease activity score (DAS28) value--for the decision to 
maintain unchanged disease-modifying antirheumatic drug (DMARD) treatment in 
rheumatoid arthritis patients, based on expert opinion.
METHODS: Nine hundred and sixty-seven case scenarios with various levels for 
each component of the DAS28 (resulting in a disease activity score between 2 and 
3.2) were presented to 44 panelists. For each scenario, panelists had to decide 
whether or not DMARD treatment (excluding steroids) could be maintained 
unchanged. In each scenario, for decision, the participants were given the DAS28 
parameters, without knowledge of the resultant DAS28. The relationship between 
panelists' decision, DAS28 value, and components of the score were analysed by 
multiple logistic regression analysis. Each panelist analysed 160 randomised 
scenarios. Intra-rater and inter-rater reproducibility were assessed.
RESULTS: Forty-four panelists participated in the study. Inter-panelist 
agreement was good (kappa = 0.63; 95% confidence interval = 0.61 to 0.65). 
Intra-panelist agreement was excellent (kappa = 0.87; 95% confidence interval = 
0.82 to 0.92). Quasi-perfect agreement was observed for DAS28 < or = 2.4, less 
pronounced between 2.5 and 2.9, and almost no agreement for DAS28 > 3.0. For 
values below 2.5, panelists agreed to maintain unchanged DMARDs; for values 
above 2.5, discrepancies occurred more frequently as the DAS28 value increased. 
Multivariate analysis confirmed the relationship between panelist's decision, 
DAS28 value and components of the DAS28. Between DAS28 of 2.4 and 3.2, a major 
determinant for panelists' decision was swollen joint count. Female and public 
practice physicians decided more often to maintain treatment unchanged.
CONCLUSIONS: As a conclusion, panelists suggested that in clinical practice 
there is no need to change DMARD treatment in rheumatoid arthritis patients with 
DAS28 < or = 2.4.