Transcript CASPAR study

CASPAR study
Philip Helliwell
Will Taylor
On behalf of the CASPAR study group
Areas to be covered
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What is the CASPAR study?
What happened before CASPAR?
What is the future beyond CASPAR?
Will it change our daily practice?
Aim of CASPAR
• To compare the test performance
characteristics of existing classification
criteria
• To determine whether new criteria derived
from observed data would be more
accurate than these existing criteria
What happened before CASPAR?
Most authors used Moll and Wright
– Inflammatory arthritis, psoriasis and the (usual)
absence of rheumatoid factor
70
60
50
%
40
Asymmetrical
oligoarthritis
Symmetrical
polyarthritis
30
20
10
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M
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/W
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o
igh
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7
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1
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Jon
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Vasey & Espinoza
In: Calin A, editor. Spondyloarthropathies. Orlando, Florida: Grune &
Stratton; 1984. p. 151-185
Psoriatic skin or nail involvement [current psoriasis, history of psoriasis, or nail
disease]
PLUS One of these 2
(a)
1/ DIP involvement [finger DIP swollen]
Peripheral
2/ Asymmetry or dactylitis
pattern
3/ Symmetry in absence of RF and nodules
(any of):
4/ Pencil-in-cup deformity, whittling of terminal phalanges, fluffy
periostitis and bony ankylosis [radiographic osteolysis, tuft
erosion, ankylosis, or juxta-articular new bone formation]
(b) Axial
pattern
(any of):
1/ Spinal pain and stiffness with the restriction of motion present
for over 4 weeks
2/ Grade 2 symmetric sacroiliitis according to the New York criteria
3/ Grade 3 or 4 unilateral sacroiliitis
Design
• Prospective, observational study of
consecutive clinic patients with PsA and
other inflammatory arthritis (at least 50%
rheumatoid arthritis)
• Target sample size of 1012 in total
• 30 clinics in 13 countries
• Gold-standard of diagnosis based on
physician’s opinion
• Data collected between Feb 02 to Mar 04
CASPAR was a first!
• CASPAR was the first World Wide
collaboration of committed researchers in
psoriatic arthritis
• The forerunner of GRAPPA
• Bigger (and better) than any of the other
rheumatological criteria sets
Demographics of CASPAR population (n = 1124)
PsA (n=588)
Controls (n=536)
Disease (%)
PsA (100)
RA (70), AS (13), UA (7),
CTD (3), other (5)
Age, yrs (mean, SE)
50.3 (0.54)
55.2 (0.62)*
Disease duration, yrs
(mean, SE)
12.5 (0.40)
13.3 (0.46)
Male (%)
52.0
37.0*
RF positive (%)
4.6
57.3*
Anti-CCP positive (%)
7.6
54.5*
PASI (median, range)
2.15 (0 to 54)
* p<0.001
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
CASPAR criteria (Specificity 0.987, sensitivity 0.914)
Inflammatory articular disease (joint, spine, or entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
Psoriatic skin or scalp disease present today as
judged by a dermatologist
2. Personal history of psoriasis (if current
psoriasis not present)
A history of psoriasis that may be obtained from
patient, family doctor, dermatologist or
rheumatologist
3. Family history of psoriasis (if personal history
of psoriasis or current psoriasis is not present)
A history of psoriasis in a first or second degree
relative according to patient report
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis is not
present)
8. Radiological evidence of juxta-articular new
bone formation
Typical psoriatic nail dystrophy including
onycholysis, pitting and hyperkeratosis observed
on current physical examination
By any method except latex but preferably by
ELISA or nephlemetry, according to the local
laboratory reference range
Swelling of an entire digit
A history of dactylitis recorded by a
rheumatologist
Ill-defined ossification near joint margins (but
excluding osteophyte formation) on plain xrays of
hand or foot
The CASPAR criteria
• Why didn’t spinal features appear in the criteria?
• Why didn’t enthesitis appear in the criteria?
• What is the definition of ‘inflammatory articular
disease’?
• Are these criteria suitable for classifying early
disease?
• Are these criteria suitable for diagnosis at the
bedside?
The bedside exceptions
• Combination of a dactylitic
toe and Achilles tendon
insertional enthesitis
• A swollen knee and nail
pitting
• Seronegative polyarticular
disease, a family history of
psoriasis in a first degree
relative and severe
radiological osteolysis
• Unilateral sacroiliitis and a
history of psoriasis
What is planned for the future?
• For now CASPAR criteria should be used for
clinical trials: permits uniformity and moves
towards homogeneity
• Further development:
– Planned studies:
• Clinical and radiological examination of a population of
subjects with psoriasis and articular symptoms (screening
questionnaire)
• Prospective study of a population of subjects with early
disease
• Closer look at CCP positive subjects
CASPAR – Development and validation of classification
criteria for psoriatic arthritis
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UK: Dr L Kay, Newcastle; Dr A Adebajo, Sheffield; Dr A Isdale,
Northallerton; Prof P Emery, Leeds; Dr D McGonagle, Halifax; Dr N
McHugh, Bath, P Helliwell, Bradford
Belgium: Prof Herman Mielants, Dr K DeVlam.
Italy: Dr A Marchesoni, Dr I Olivieri, Dr C Salvarani, Dr E Lubrano.
Spain; JC Torre-Alonso
France: Prof B Fournie, Prof M Dougados.
Sweden: Dr B Svensson, Dr S Dahlqvist, Dr Alenius
Canada: Prof D Gladman, Prof A Russell.
New Zealand: Dr W Taylor.
South Africa: Prof Girish Modi, Dr A Kalla.
Morocco: Prof Houssani.
Australia: Dr M Lassere.
Ireland: Dr D Veale, Dr O Fitzgerald.
United States: Dr Luis Espinoza, Dr P Mease, Dr C Ritchlin.
Main Centre: University of Leeds, UK
Acknowledgements
• Funding: EULAR, Barnsley District NHS Trust, Groote
Schuur Hospital (Cape Town), Department of Medical
Sciences (University Hospital, Uppsala), Krembil
Foundation, St. Vincent’s University Hospital Radiology
Department (Dublin), Inkosi Albert Luthuli Central
Hospital (Durban), El Ayachi Hospital (Morocco),
National Psoriasis Foundation (USA), The Foundation
for Scientific Research of the Belgian Society of
Rhumatology, Arthritis New Zealand.
• Radiology: Guy Porter, Keighley, UK
• CCP analysis: Neil McHugh, Pat Owen, Bath, UK
• Statistical analysis: Will Taylor, John Horwood, NZ