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Extended report
▶ Additional data are
published online only at
http://ard.bmj.com/content/
vol69/issue3
1Division of Rheumatology,
Department of Medicine 3,
Medical University of Vienna,
Vienna, Austria
2Division of Rheumatology,
Department of Medicine 4,
Hanusch Hospital, Vienna,
Austria
3Second Department of
Medicine, Hietzing Hospital,
Vienna, Austria
Correspondence to
Professor Josef S Smolen,
Division of Rheumatology,
Department of Medicine 3,
Medical University of Vienna,
Waehringer Guertel 18-20,
A-1090 Vienna, Austria; josef.
smolen@wienkav.at
Accepted 29 August 2009
546
Evaluation of the appropriateness of composite disease
activity measures for assessment of psoriatic arthritis
Valerie P Nell-Duxneuner,1,2 Tanja A Stamm,1 Klaus P Machold,1 Stephan Pflugbeil,3
Daniel Aletaha,1 Josef S Smolen1,3
ABSTRACT
Objective Specific composite indices assessing
disease activity in psoriatic arthritis (PsA) have not yet
been sufficiently validated. The objective of this study
was to identify instruments best reflecting disease
activity in PsA.
Methods Measures for inclusion in clinical trials, as
recommended by the OMERACT-7/8 PsA workshops,
were assessed. A principal component analysis (PCA)
was performed with cross-sectional data of 105
patients with PsA to identify a minimal set of important
dimensions for a disease activity assessment tool for
PsA. This was compared with components contained in
existing composite indices.
Results The PCA revealed four principal components
best reflecting disease activity. The first contained
patient global and pain assessment; the second
contained 66/68 swollen and tender joint counts as
main variables; C-reactive protein (CRP) best loaded
to the third component; and the fourth was loaded by
skin assessment but did not reach significance. When
comparing the three significant principal components
with items of established composite measures, they were
best covered by the Disease Activity Index for Reactive
Arthritis (DAREA) which comprises patient pain and
global assessments, 66/68 joint counts and CRP.
Conclusion Among the currently available indices
used in arthritic conditions, the DAREA best reflects the
domains found to be important in PsA.
INTRODUCTION
Psoriatic arthritis (PsA) is an inflammatory joint
disease associated with psoriasis, presenting as
peripheral arthritis often accompanied by spinal
involvement and enthesitis. Different instruments
are employed for disease evaluation,1 most focus-
ing on individual characteristics and therefore not
spanning the disease spectrum. Even for arthritis,
the instruments are insufficiently validated or “bor-
rowed” from rheumatoid arthritis (RA) assessment.
In contrast to RA, arthritis in PsA is often asym-
metrical and oligoarticular, frequently involving
distal interphalangeal joints (DIPs). Compared
with ankylosing spondylitis, in PsA spinal involve-
ment is infrequent, commonly asymmetrical and
discontinuous.2
PsA shows variable signs and symptoms between
and within individual patients. Composite dis-
ease activity indices compensate for such limi-
tation.3 In ballots on important domains at PsA
workshops (Outcome MEasures in Rheumatoid
Arthritis Clinical Trials OMERACT-7/8),4 5 vari-
ous items received majority votes, suggesting that
they partly provided different information and
should therefore be contained in potential compos-
ite scores. While several composite activity indices
are used in PsA,6 they were mostly not developed
for PsA and encompass only a few variables with
majority votes.
We thus evaluated domains important for PsA
assessment regarding commonalities and dispari-
ties in their ability to generate components for der-
ivation of a disease activity score for PsA.
PATIENTS AND METHODS
Consenting outpatients (n=105) classified as hav-
ing PsA7 were evaluated at two follow-up visits
about 3 months apart. An independent biometri-
cian performed assessments. The study, approved
by the ethical committee, did not require treatment
alterations.
In a cross-sectional primary analysis, we focused on
variables having ≥50% of the votes at OMERACT-74
(for details see online supplement). In a sensitivity
analysis we additionally performed assessments that
included all tested variables (see online supplement).
Analyses
Principal component analysis (PCA) was chosen
to generate a smaller number of combinations of
variables accounting for most of the variability (see
online supplement). Only loadings >0.3 are demon-
strated. The “Eigenvalue” should be >1.0 for each
component.
Sample size
In PCA, the ratio of subjects to items is impor-
tant, ≥10 cases per item being ideal. With 105
patients and 11 items, we have accounted for this
recommendation.
RESULTS
Patient characteristics
The baseline characteristics of the patients are
shown in the online supplement. Table 1 presents
the data included in PCA on the first and second
visits.
Principal component analysis
After obtaining significance supporting the overall
approach (see online supplement), PCA revealed
simple structures: four components showed strong
loadings (table 2).
The first component contained patient global
assessment (PtGA) and pain followed by the Bath
Ankylosing Spondylitis Disease Activity Index
(BASDAI) and represented “patient self-reported
disease activity”. The second component (“joints”)
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Extended report

Table 1 Variables included in principal component analysis at first and Table 2 Principal component analysis
second visit
Rotated component matrix
First visit Second visit
1 2 3 4
VAS PtGA (mm) 36.7 (25) 34.3 (23.9)
VAS PtGA 0.893
VAS PAIN (mm) 35.4 (25) 30.2 (23.3)*
VAS PAIN 0.877
BASDAI 3.8 (2.3) 3.7 (2.3)
BASDAI 0.807 0.319
SF-36 MCS 60.4 (25.1) 63.4 (23.7)
SF-36 MCS −0.724
HAQ 0.6 (0.6) 0.6 (0.6)
HAQ 0.636 0.440
66 SJC 2.7 (4.1) 2.2 (4.2)
66 SJC 0.868
68 TJC 5.2 (7.4) 6.3 (12)
68 TJC 0.361 0.854
Enthesitis score 0.7 (1.7) 0.4 (1.3)
Enthesitis 0.365 0.554
CRP (mg/dl) 1.4 (3.1) 0.9 (1.8)
CRP 0.901
ESR (mm) 14.7 (17.3) 15.6 (19.5)
ESR 0.827 0.352
PASI 3.3 (6.1) 3.1 (6.1)
PASI 0.949
The variables represent the domains proposed by the OMERACT-7 PsA module. Mean
values (±SD) are shown. Varimax rotation of four component (1–4) solution for PsA disease activity items. The
*p=0.002 for difference between first and second visit; differences otherwise not significant. loading of each variable on the four components is shown.
BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; CRP, C-reactive protein; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; CRP, C-reactive protein;
ESR, erythrocyte sedimentation rate; HAQ, health assessment questionnaire; PASI, ESR, erythrocyte sedimentation rate; HAQ, health assessment questionnaire; PASI,
psoriasis area and severity index; SF-36 MCS, Short Form-36 health survey Mental psoriasis area and severity index; SF-36 MCS, Short Form-36 health survey Mental
Component Summary; SJC, swollen joint count; TJC, tender joint count; VAS PAIN, Components Summary; SJC, swollen joint count; TJC, tender joint count; VAS PAIN,
visual analogue scale patient pain assessment; VAS PtGA, visual analogue scale patient visual analogue scale patient pain assessment; VAS PtGA, visual analogue scale patient
global disease activity assessment. global disease activity assessment.

contained swollen (SJC) and tender (TJC) joint counts as the
main loading variables. The third was best loaded by C-reactive
protein (CRP) and erythrocyte sedimentation rate, and the fourth
by the “skin factor” Psoriasis Area and Severity Index (PASI), but
did not reach significance (Eigenvalue <1.0).
Thus, assessment of PsA can be “reduced” to three significant
principal components: patient self-reported disease activity,
joint counts and acute phase reactants (APR).
Sensitivity analyses
Change over time
All patients were reassessed after about 3 months, allowing
changes in activity to be evaluated. While changes were small
(table 1), repeating PCA using the differences between visits
gave similar results to the primary PCA. Again, the first compo-
nent contained changes in pain and PtGA, the second contained
change in APR, the third was best loaded by changes in SJC and
TJC and the fourth by change in PASI.
Confirmatory PCA using more variables
Additional sensitivity analysis using 22 variables (see online
supplement) showed five components with Eigenvalues >1.0.
The first was again loaded most strongly by PtGA and pain. The
second was new, showing self-reported function as an individ-
ual component best represented by the Dougados Functional
Index (DFI) and Health Assessment Questionnaire (HAQ). The
third component, representing “joints”, showed higher load-
ings for 66/68 than 28 joint counts. Interestingly, although low,
enthesitis also loaded in this but no other component. The
fourth and fifth components were loaded mainly by skin (PASI)
and APR (CRP). The confirmatory PCA corroborated our pri-
mary PCA, showing the same major components and variables
complemented by a component on functional status.
Comparison of PCA data with disease activity and response criteria
Variables best representing the principal components should
obviously be included in a possible composite disease activity
index. Tables 3 and 4 show domains of various disease activity
(table 3) and response measures (table 4) compared with PCA
results.
The Disease Activity Score using 28 TJS/SJC (DAS28)8 comprises
four variables, but not pain; it uses reduced joint counts. The
Simplified and Clinical Disease Activity Indices (SDAI, CDAI)
have the same limitation,9 10 CDAI also lacking APR. In contrast,
the Disease Activity index for REactive Arthritis (DAREA)11
comprises variables contained in all PCA components, includ-
ing 66/68 joint counts and CRP. The ACR criteria comprise five
variables12: the EULAR criteria are limited by using DAS2813
and the Psoriasis Arthritis Response Criteria (PsARC)14 lack pain
and APR.
DISCUSSION
To date, there are no specific well-validated disease activity
measures in PsA. Although measures “borrowed” from other
rheumatic diseases are used in clinical trials, there are insuffi-
cient data showing which item composition best reflects PsA
joint disease activity.
The data presented here using PCA seem to draw a clear
picture of the areas important in PsA. Patient-reported disease
activity represented the first component, loaded mostly by
pain and PtGA and less by the BASDAI, SF-36 and HAQ. Spine
involvement did not attain its own component by PCA in either
our primary or confirmatory PCA. However, in this confirma-
tory PCA, functional assessment comprised a separate compo-
nent with the DFI and HAQ achieving highest loadings. Since
the DFI has not been validated in PsA while the HAQ has been
used in recent clinical trials,15 16 we propose to use the HAQ
in the follow-up of patients with PsA but not to include it in a
composite measure as it is multifactorial and contains irrevers-
ible elements.17
Joint involvement constituted the second domain. Our con-
firmatory PCA showed 28 joint counts loading less strongly
than 66/68 counts. Indeed, many patients with PsA have
inflammation of DIPs and foot joints not captured by 28 joint
counts.
The third component showed that APR loaded separately
with no significant overlap with other components. Clinical trial
data suggest a worse outcome in PsA with raised APR,18 and
that APR are sensitive to change.16 Interestingly, in contrast to
OMERACT-7, the second voting at OMERACT-8 rejected APR

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Extended report

Table 3 Demonstration of the domains contained in various composite Table 4 Demonstration of the domains contained in various response criteria in
disease activity measures in comparison with the variables loading best comparison with the variables loading best in the principal component analysis
in the principal component analysis
Two Response criteria
Two Composite scores highest
highest loading
loading variables
variables per
per component PsARC ACR EULAR
component DAS28 SDAI CDAI DAREA
Component I: Patient self- VAS PtGA + + + + Component I: Patient self-reported VAS PtGA + + +
reported disease activity disease activity VAS PAIN − + −
VAS PAIN − − − +
Component II: Joint counts 66 SJC + + −*
Component II: Joint counts 66 SJC −* −* −* +
68 TJC + + −*
68 TJC −* −* −* +
Component III: Acute phase CRP −** + − + Component III: Acute phase reactants CRP − −
reactants ESR − +either/or +
ESR + − − −
*Based on 28 joint counts. *Based on 28 joint counts.
**DAS28 has been modified for the use of CRP rather than ESR but this is not sufficiently ACR, ACR response criteria; CRP, C-reactive protein; ESR, erythrocyte sedimentation
validated. rate; EULAR, EULAR response criteria; PsARC, Psoriatic Arthritis Response Criteria;
CDAI, clinical disease activity index; CRP, C-reactive protein; DAREA, Disease Activity SJC, swollen joint count; TJC, tender joint count; VAS PAIN, visual analogue scale
index for REactive Arthritis; DAS28, disease activity index based on 28 joint count; ESR, patient pain assessment; VAS PtGA, visual analogue scale patient global disease activity
erythrocyte sedimentation rate; SDAI, simplified disease activity index; SJC, swollen joint assessment.
count; TJC, tender joint count; VAS PAIN, visual analogue scale patient pain assessment;
VAS PtGA, visual analogue scale patient global disease activity assessment;

where reduced joint counts reflect the overall joint involvement

as an important domain;5 our data support OMERACT-7 and
first OMERACT-8 votings.
The fourth component captured skin involvement with no
overlap with any other domain, suggesting that severity of skin
disease has no impact on arthritic activity. We certainly propose
including dermatological evaluation and treatment in overall
patient care, but it seems that skin involvement should be eval-
uated separately.
It is noteworthy that enthesitis did not load importantly to
the components. This suggests that joint and entheseal pain may
run different courses, do not occur together frequently, or that
enthesitis may be less prevalent or less ailing than envisaged.
When looking at composite measures, the DAS28, EULAR
response, SDAI and CDAI—all developed for RA—do not
represent the principal components of PsA sufficiently since
they use reduced joint counts and lack pain; indeed, the limita-
tions of using DAS28 in PsA have recently been addressed.19
Also PsARC, developed for PsA, is not limited by either the
inclusion of pain or APR. In contrast, ACR improvement criteria
cover all components but do not reflect actual disease activity.
Interestingly, DAREA, a score developed and validated for reac-
tive arthritis and thus in a PsA-related disease,11 comprises all the
major components: pain, PtGA, 66/68 SJC/TJC and CRP. Of all
the available indices, DAREA therefore best reflects the domains
important in PsA and may thus serve as a Disease Activity index
for PSoriatic Arthritis (DAPSA). Indeed, in a preliminary analysis
it showed validity and sensitivity to change in an observational
cohort of patients with PsA.20
In a sensitivity analysis on changes over time, the highest
loadings were exhibited by the same variables as in the origi-
nal PCA. Thus, DAREA comprises the variables loading most
strongly and significantly. Since mathematically it sums five
variables, it is easy to perform in routine settings. Assessment of
function by questionnaires such as the HAQ and assessment of
skin, spine and entheseal involvement will expand information
to disability and extra-articular features.
Since the joint is the primary organ involved in PsA, we feel
that joint counts should be included in composite indices and
not bypassed using surrogates which would not do justice to the
patients or the caretaking physician. Moreover, in contrast to RA
well, comprehensive joint counts are needed for composite scores
in PsA. Whether a composite measure also needs to comprise an
APR will have to be determined separately. Clearly, the data sug-
gest that skin, spine and entheseal involvement do not provide
information on arthritic disease activity and should not be part of
a composite score for PsA. However, as they capture important
aspects of the disease, they should be assessed separately.
Our data suggest that developing a new score is not needed
for the assessment of PsA since DAREA/DAPSA contains all the
major components found to be important by PCA. Final valida-
tion in clinical trials of PsA is needed and planned.
Acknowledgement This study was partly funded by a grant from GRAPPA (Group for
Research and Assessments of Psoriasis and Psoriatic Arthritis).
Ethics approval This study was conducted with the approval of the Medical
University of Vienna.
Provenance and peer review Not commissioned; externally peer reviewed.
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549
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Evaluation of the appropriateness of

composite disease activity measures for
assessment of psoriatic arthritis
Valerie P Nell-Duxneuner, Tanja A Stamm, Klaus P Machold, Stephan
Pflugbeil, Daniel Aletaha and Josef S Smolen

Ann Rheum Dis 2010 69: 546-549 originally published online September
17, 2009
doi: 10.1136/ard.2009.117945

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http://ard.bmj.com/content/69/3/546

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Material http://ard.bmj.com/content/suppl/2010/04/16/ard.2009.117945.DC1.ht
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Collections Degenerative joint disease (4250)
Musculoskeletal syndromes (4542)
Pain (neurology) (812)

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