GRAPPA - Group for Research and Assessment of Psoriasis and Psoriatic Arthritis

GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) is organized exclusively for non-profit, educational, and scientific purposes, specifically to facilitate sharing of information related to psoriasis and psoriatic arthritis, networking among different medical disciplines that see psoriasis and psoriatic arthritis patients and to enhance research, diagnosis and treatment of psoriasis and psoriatic arthritis.

Originally inspired by the Assessment in Ankylosing Spondylitis Working Group (ASAS), GRAPPA was formed in 2003. GRAPPA has pulled together many different groups, including pre-eminent researchers and thought-leaders in psoriatic arthritis (PsA) and psoriasis (PsO). The inaugural meeting of GRAPPA was held in August 2003, where a consensus exercise started the group toward prioritizing domains of inquiry in PsA and PsO. Subsequent meetings have focused on identifying and initiating research projects, advancing standardized criteria for psoriatic arthritis registries and developing treatment guidelines for PsA.
 

Today, approximately 453 thought-leaders participate in GRAPPA including rheumatologists, dermatologists, radiologists, geneticists, methodologists, epidemiologists, representatives from patient service leagues and biopharmaceutical industry representatives. Approximately 60% of participants live and work outside North America, creating a truly international effort.

Here we present a few key highlights from the last GRAPPA Annual Meeting, held in Naples in July 2011.

GRAPPA Video Project

Kristina Callis Duffin and Philip Mease presented an update on the GRAPPA video project at the GRAPPA 2011 conference.  The key objective of the video project was to develop and validate a set of high quality presentations for use as interactive web-based training modules.  Significant progress has been made since the previous GRAPPA meeting in 2010, notably: publication of the video project in the Journal of Rheumatology, recruitment of four industry users of the video project for clinical trials, and the completion of validation exercises.

April Armstrong presented results from the validation exercises showing that prior to video training, both patients and PASI-naïve physicians tended to give higher PASI assessments for mild, moderate and severely diseased patients than PASI-experienced physicians.  After the video training exercise, both patient-assessed PASI and PASI-naïve physician assessments improved to more closely match that of experienced physicians, although a statistically significant difference remained for both groups when evaluating patients with severe psoriasis.

Kristina Callis Duffin demonstrating clinical examination for the GRAPPA training videos

The following modules are available: Modified NAPSI, NAPSI, PASI/BSA, PGA 5 Point (0-4), PGA 6 Point (0-5), PPPASI (palmar plantar), PSSI (scalp module), TPSS (Total Plaque Severity Score), and Assessment of Enthesitis and Dactylitis in Psoriatic Arthritis.  A completion certificate may be printed after completion of a module.

Biomarkers in Psoriatic Arthritis

The diagnosis and therapy of psoriatic arthritis is often challenging because we lack susceptibility markers for arthritis in psoriasis patients and also markers that can distinguish patients who will develop radiographic progression in early disease.  For this reason, the search for biomarkers to distinguish those patients with psoriasis who have developed or will develop psoriatic arthritis has been a major effort in the field.  In addition, biomarkers which represent disease activity in PsA, measure treatment response and predict radiographic outcomes such as erosion and new bone formation could dramatically improve clinical care.  While several potential biomarkers have been proposed, much work remains to be done to identify biomarkers that fulfil the OMERACT filter (truth, discrimination, and feasibility) in studies with well defined cases and controls.  GRAPPA is in the planning stages for a large observational study known as “PsA BioDam” in conjunction with the OMERACT biomarker working group.  This effort has been modelled after the RA BioDam trial, an observational biomarker study to define biomarkers in rheumatoid arthritis.  The primary objective of PsA BioDam is to conduct a well designed observational study to determine the independent predictive validity of high priority candidate biomarkers for predicting structural damage in PsA.  Secondary objectives including examining whether clinical and laboratory markers (alone or in combination) can predict progressive disease.  Patients enrolled will be followed over the course of routine clinical care for a minimum of 24 months.  Current efforts centre on finalizing the study design and procurement of funding.  Details of progress in this area will be discussed at the EULAR Meeting in Berlin.

Screening Psoriasis patients for Psoriatic Arthritis

Identifying an optimal screening tool for the detection of psoriatic arthritis among patients with psoriasis has been a major initiative within GRAPPA.  During the 2009 Annual GRAPPA meeting, of 47 members were surveyed, 95.7% felt that dermatologists should screen psoriasis patients for PsA and 83% thought that a questionnaire should be used for screening.   Five psoriatic arthritis screening questionnaires have been designed to date: PAQ (Canada and Sweden), PASE (Boston), TOPAS (Toronto), PEST (Leeds), and PASQ (Newfoundland).   TOPAS, PASE and PEST are the mostly widely used.  While each performs well in the population in which it was designed, efforts are now underway to determine which questionnaire performs best overall in identifying PsA.  During the 2011 GRAPPA meeting in Naples, Dr. Philip Helliwell presented initial results from a study to address this question: CONTEST (COmparisoN of ThreE Screening Tools) includes several sites in the UK (Leeds, Bath, London, Newcastle, Manchester and Bradford).   As a part of the study, patients with psoriasis over the age of 16 and without a prior diagnosis of PsA were given all three surveys (randomly arranged in packets).  Of 581 surveys distributed, 306 were returned and 147 patients screened positive according to at least one tool.  Of those with a positive screening test, 78 patients were examined and 17 were found to have PsA.  Initial area under the curve for TOPAS, PASE, and PEST were 0.65, 0.52, and 0.75 respectively.  Final results from this study are expected this year.  At the 2011 American College of Rheumatology Conference in Chicago, Jessica Walsh, Daniel Clegg, and Kristina Callis Duffin presented a similar study performed among 158 patients within the Utah Psoriasis Initiative; this group included patients with known PsA (44% were on DMARDs).   While sensitivity was reasonable (TOPAS 0.93, PEST 0.89, PASE 0.68), specificity was low, ranging from 0.49-0.64.

GRAPPA Goals

• Provide a forum for networking and communication between international researchers in rheumatology and dermatology, industry, patient service leagues and regulatory agencies
• Provide the opportunity for in-person meetings and intranet communication to share knowledge, research findings, and develop or conduct collaborative research, education and other projects
• Develop and validate a criteria set for the definition of psoriatic arthritis (PsA)
• Review, develop and validate effective and feasible outcome measures for the assessment of PsA and psoriasis (PsO)
• Promote the development of national and international collaborative registries of PsA and PsO patients to standardize the data being obtained and learn more about the natural history of the disease as well as its genetic underpinnings
• Work closely with representatives of patient service leagues to promote public education and awareness of PsA and PsO
• Work closely with representatives of biopharmaceutical companies to promote and conduct research on effective therapies for PsA and PsO
• Work closely with representatives of regulatory agencies to establish appropriate guidelines for regulatory approval of new therapies
• Work with other professional bodies, such as the American College of Rheumatology, American Academy of Dermatology, and OMERACT to promote knowledge of research about PsA and PsO within the context of those disciplines
• Develop treatment guidelines for governmental and other interested parties

Zoe Ash, with thanks to Alexis Ogdie, Shiu-chung Au and Pam Love