Assessment of enthesitis in
psoriatic arthritis
Philip Helliwell
University of Leeds
Assessment of enthesitis in
psoriatic arthritis – why bother?
• Enthesis suggested as hallmark pathoanatomical feature
• Clinical and radiological enthesopathy one
of distinguishing clinical features for
spondyloarthropathy and psoriatic arthritis
• Active clinical involvement may reflect
general disease activity
What instruments already exist?
• Mander enthesitis index (MEI)
–
Mander M, Simpson JM, McLellan A, Walker D, Goodacre JA, Dick WC. Studies with an enthesis index as a
method of clinical assessment in ankylosing spondylitis. Ann rheum Dis 1987; 46:197-202.
• MASES
–
Heuft-Dorenbosch L, Spoorenberg A, van Tubergen A, Landewe R, van der Tempel H, Mielants H et al.
Assessment of enthesitis in ankylosing spondylitis. Annals of the Rheumatic Diseases 2003; 62:127-132.
• SPARCC
–
Gladman DD, Cook RJ, Schentag C, Feletar M, Inman RI, Hitchon C et al. The clinical assessment of
patients with psoriatic arthritis: results of a reliability study of the spondyloarthritis research consortium of
Canada. J Rheum 2004; 31(6):1126-1131.
• MAJOR
–
Braun J, Brandt J, Listing J, Zink A, Alten R, Golder W et al. Treatment of active ankylosing
spondylitis with infliximab: a randomised controlled multicentre trial. Lancet 359(9313):118793, 2002.
Mander (MEI) enthesitis index
•Nuchal crests
•Manubriosternal joints
•Costochondral joints
Basic score
uses graded
response with
score range
0-90
Modified
score uses
binary
response with
score range
0-30
•Greater tuberosity of
humerus
•Lateral and medial
epicondyles of humerus
•Iliac crests
•Ant sup iliac spines
•Greater trochanter of
femur
•Medial and lateral
condyles of femur
•Insertion of Achilles
tendons
•Insertion of plantar fascia
•Cervical, thoracic and
lumbar spinous processes
•Ischial tuberosities
•Post sup iliac spines
MASES enthesis index
•Reduced number of sites (13)
•Removed grading of tenderness
(binary response)
•Avoided joint margins
•Better reliability
• 1st Costochondral joints
•7th costochondral joints
•Iliac crests
•Ant sup iliac spines
•Insertion of Achilles tendons
•lumbar spinous processes
•Post sup iliac spines
SPARCC enthesis index
•8 sites
•Not graded
•Reliability shown in
SPARCC study
(Gladman et al. J
Rheum 2004;
31(6):1126-1131)
•Greater tuberosity of
humerus
•Insertion of Achilles
tendons
•Insertion of plantar fascia
•Tibial tuberosity
MAJOR enthesis index
Graded as
present/absence of
tenderness
•Iliac crests
•Greater trochanter of
femur
•Medial and lateral
condyles of femur
•Insertion of Achilles
tendons
•Insertion of plantar fascia
Reliability of enthesitis indices
Results from INSPIRE study
Figures are ICC (95% CI)
Psoriatic arthritis
MAJOR
0.70 (0.5 – 0.89)
MASES
0.56 (0.34 – 0.82)
SPARCC
0.81 (0.64 – 0.93)
Ankylosing
spondylitis
A new index for psoriatic arthritis
• 28 Ss with ‘active’ psoriatic arthritis
starting treatment with new DMARDs
• All had enthesitis assessed at each of 5
visits over 6 months
• MEI (x2), MASES, SPARCC, MAJOR
• On final dataset performed data reduction
using method of Heuft-Dorenbosch
Heuft-Dorenbosch L, Spoorenberg A, van Tubergen A, Landewe R, van der Tempel H,
Mielants H et al. Assessment of enthesitis in ankylosing spondylitis. Annals of the Rheumatic Diseases
2003; 62:127-132.
A new index for psoriatic arthritis
• All MEI entheseal points graded to binary
• Frequency tables – entheseal point found
to be most frequently tender, noted, and
these patients not included in next ‘round’
• Process repeated until 80% assessments
included
A new index for psoriatic arthritis
• 80% of assessments included after just 3
‘rounds’
– 1st round: right lateral epicondyle (49%)
– 2nd round: right medial femoral condyle (70%)
– 3rd round: right PSIS, Cx spinous process and
left Achilles insertion were equal (80%)
• LENIN: right and left lateral epicondyle
humerus, right and left medial femoral
condyle, right and left AT insertion (max 6)
Change in enthesis scores
following treatment change
3.5
3
2.5
2
1.5
1
0.5
0
m
on
th
s
s
Si
x
m
on
th
h
on
t
Th
re
e
m
ne
O
B
as
el
in
e
MEI (0.40)
MEI mod (1.03)
MASES (0.76)
MAJOR (1.19)
SPARCC (1.05)
LENIN (1.19)
MEI scores are
divided by 10
Relationship between enthesis indices and other
measures of disease activity
0.6
Spearman rho
0.4
0.2
MEItotal
MASES
SPARCC
MAJOR
LENIN
0
-0.2
-0.4
Values >±0.2 are significant
LD
I
le
n
Sw
ol
Te
nd
e
r
t
VA
Sp
s
hy
VA
Sp
C
R
P
-0.6
Assessment of enthesitis in
psoriatic arthritis
• Indices developed in patients with ankylosing
spondylitis seem to function well in psoriatic
arthritis
– Repeatability
– Responsiveness
– Relation to other measures of disease activity
• New index derived from psoriatic arthritis
population also functions well, although possibly
not as well, has good effect size, and is quick
and simple to perform
The OMERACT filter
• Truth
– Poor relationship between clinical and U/S detected enthesitis
– Juxta-articular position of entheses may lead to confounding with
articular pain
• Discrimination
– All indices able to discriminate between states of low and high
disease activity (data not shown)
– All indices show good responsiveness and effect sizes
• Feasability
– LENIN is quickest and easiest but all others, excepting MEI, are
also simple to perform
Acknowledgements
• Rose Hellaby Trust supported Paul
Healy
• Sanofi-Aventis provided funding for the
study and the MRI scans (dactylitis)