1. CASPAR study Philip Helliwell Will Taylor On behalf of the CASPAR study group

2. Areas to be covered What is the CASPAR study? What happened before CASPAR? What is the future beyond CASPAR? Will it change our daily practice?

3. 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

4. What happened before CASPAR? Most authors used Moll and Wright –Inflammatory arthritis, psoriasis and the (usual) absence of rheumatoid factor

5. 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) Peripheral pattern (any of): 1/ DIP involvement [finger DIP swollen] 2/ Asymmetry or dactylitis 3/ Symmetry in absence of RF and nodules 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

6. 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

7. 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

8. 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 (%)52.037.0* RF positive (%)4.657.3* Anti-CCP positive (%)7.654.5* PASI (median, range)2.15 (0 to 54) * p<0.001 Demographics of CASPAR population (n = 1124)

9. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

10. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

11. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

12. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

13. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

14. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

15. 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 Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis observed on current physical examination 5. A negative test for rheumatoid factor By any method except latex but preferably by ELISA or nephlemetry, according to the local laboratory reference range 6. Current dactylitis Swelling of an entire digit 7. History of dactylitis (if current dactylitis is not present) A history of dactylitis recorded by a rheumatologist 8. Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (but excluding osteophyte formation) on plain xrays of hand or foot

16. 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?

17. 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

18. 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

19. CASPAR – Development and validation of classification criteria for psoriatic arthritis 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

20. 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