The Importance of Clinical Specificity: A Review of FDA Cleared
Fecal Calprotectin Tests
Bethany Bell, PhD†
Andrea Tarbet†
Abstract
Symptoms shared between inflammatory bowel disease
(IBD) and irritable bowel syndrome (IBS) can make it
challenging for gastroenterologists (GIs) to quickly and
accurately determine the correct diagnosis for patients. 1,2,4
A hallmark feature of IBD that is not present in IBS is
mucosal inflammation which can be identified through
either an invasive colonoscopy, or by noninvasively
measuring fecal calprotectin. 5-9
Measuring fecal
calprotectin assists GIs by efficiently and effectively
differentiating IBD from IBS, thereby reducing the number
of unnecessary colonoscopies for those patients with IBS.1,5-10
Until recently, clinical laboratories and their physician clients
had seven FDA cleared fecal calprotectin tests available
to choose from; however, there are several known
shortcomings with many of these tests, including low
clinical specificity.
1,9,11,12
A review of the clinical specificity
of these fecal calprotectin tests demonstrates that
there is low clinical accuracy for excluding IBD as
a diagnosis in IBS patients, therefore leading to
unnecessary colonoscopies, which are invasive and
costly procedures.11 As a result, a chemiluminescence
based calprotectin ELISA was recently developed to
provide clinical laboratories and gastroenterologists with
an FDA cleared fecal calprotectin test that can more
accurately differentiate IBD from IBS and thus ensure
that patients enter the correct care pathway faster.13
Background
IBD and IBS, which affect millions of patients globally,
ALPCO, Salem, NH
†
are two distinct gastrointestinal tract disorders
that present with similar clinical symptoms.1,2,4,14,15
Therefore, determining the correct diagnosis for
patients can be an ongoing challenge for GIs.1,2,4
Because of this, many IBD patients experience a delay of
greater than 1-2 years from onset of initial symptoms to a
correct and final diagnosis.1,2,4 The most common IBD patient
self-reported reason for the delay in IBD diagnosis was an
inaccurate initial diagnosis by their clinician.2,4 Additionally,
a prolonged delay in the accurate diagnosis has been
associated with poor overall outcomes in IBD patients.2,4
Although there are clinical symptoms of IBD and IBS that
overlap, there are distinct differences that exist between
IBD and IBS such as etiology, risk of developing related
complications, and treatment options. Therefore, it is
vital for GIs to have access to tools which allow them to
quickly and accurately differentiate IBD from IBS.2,4
Guidelines from professional medical associations such as
the American College of Gastroenterology (ACG) and the
National Institute for Health and Care Excellence (NICE-UK)
recommend that patients suspected of having either IBD
or IBS are screened for fecal calprotectin levels.18,19 Levels
above the recommended cut-off of 50 µg/g are indicative
of mucosal inflammation which is then confirmed through a
colonoscopy.5,9,20 Symptomatic patients that fall below 50 µg/g
are more likely to have IBS.5,7,9,20

FDA 510(k) Cleared Fecal Calprotectin Tests
There are currently eight FDA cleared fecal calprotectin
tests commercially available to clinical laboratories.
However, in many of these tests, there are several known
problems including low clinical specificity, high false positive
rates, and variable cut-off values.1,9,12 Consequently, a
significant percentage of patients screened for mucosal
inflammation with a fecal calprotectin test are still
referred for a colonoscopy when it is unnecessary.
Thus, it is essential for clinical laboratories and
gastroenterologists to fully understand each clinical
characteristic of a fecal calprotectin test in order
to choose the one that will allow them to accurately
differentiate IBD from IBS, to exclude patients with IBS
from receiving a needless endoscopic procedure.
510(k) Submission Process for Calprotectin Tests
During the premarket notification process, also known as
the 510(k) process, the FDA evaluates the subject device to
ensure that it is substantially equivalent to a legally marketed
device with a similar intended use and similar technological
characteristics (predicate device). To make this determination
the FDA reviews the subject device’s performance
characteristics, which include both analytical and clinical
performance characteristics. 21
For fecal calprotectin assays, the clinical diagnostic
gold standard is endoscopy, and when being compared
to the clinical diagnosis there should be an association
between the analytical results obtained using the subject
device and the presence/absence of IBD versus other
gastrointestinal conditions. This is commonly referred to
as clinical sensitivity and specificity.
Once the FDA has determined that the subject device is
substantially equivalent to the predicate device, the
2
agency will grant marketing clearance to the applicant and
subsequently make available the FDA’s 510(k) Substantial
Equivalence Determination Decision Summary and the
510(k) Summary. The 510(k) Summary provides a high-
level review of the contents of the 510(k) submission
and results of any testing with enough detail to provide
an understanding of the basis of the FDA’s substantial
equivalence determination.21
Clinical Accuracy
The clinical accuracy of a test is defined as its ability to
classify patients correctly as diseased or non-diseased in
the context of clinical truth. With respect to the utility of
calprotectin when used to differentiate between IBD and
IBS, this speaks to the test’s ability to positively identify
anyone who has IBD (true positive), and accurately rule
out anyone who has IBS (true negative). Because no test
is perfect, clinical accuracy also considers anyone who has
been identified to have IBD who does not actually have
the disease (false positive) as well as anyone who has been
identified as not having IBD who does have the disease
(false negative).22
Clinical Accuracy =
(True Positive + True Negative)
____________________________________________________________________
(True Positive + True Negative + False Positive + False Negative)
Clinical Sensitivity
The clinical sensitivity of a test is defined as its ability to
correctly identify patients with a given disease.22 With
respect to the utility of calprotectin, this speaks to the
test’s ability to positively identify anyone who has IBD.8
True Positive
Clinical Sensitivity = _________________________________
(True Positive + False Negative)

Clinical Specificity
The clinical specificity of a test is defined as its ability to
correctly identify those patients without a given disease.22
With respect to the utility of calprotectin, this speaks to
the test’s ability to exclude anyone who does not have IBD,
a subset of which may be IBS.8
True Negative
Clinical Specificity = _________________________________
(True Negative + False Positive)
Clinical Utility
Although a test may prove to be clinically accurate, accuracy
does not always reflect how the test actually impacts the
clinical diagnosis or a resulting decision.22 A clinically useful
test assists with improving healthcare efficiency, cost-
effectiveness, and patient outcomes. 22-24 The higher the
clinical utility, the more likely the test is to lead to actual
changes that matter to patients.22-24 Therefore, the higher
the clinical utility, the better the test for clinicians and their
patients.23,24
Many clinicians now seek out laboratory tests according to
their clinical utility which considers both clinical sensitivity
and clinical specificity. When the sum of clinical sensitivity
and clinical specificity is greater than or equal to 170, the
test is likely to prove clinically useful.24
Clinical Utility Score = Clinical Sensitivity + Clinical Specificity
=170 = High Clinical Utility
Clinical care is most effective when patients enter the
correct treatment pathway.23 Therefore, the most clinically
useful fecal calprotectin test would be able to accomplish
both excluding patients with normal fecal calprotectin
levels (clinical specificity) from the IBD care pathway,
and accurately identifying patients with IBD (clinical
sensitivity). 8 When the correct fecal calprotectin test
3
is chosen, patients with IBS are spared unnecessary
colonoscopies, allowing those ultimately diagnosed with
IBD earlier access to the care they need. 8,20
A Review of all 510(k) Cleared Fecal Calprotectin Tests
A review of the 510(k) summaries for the eight FDA cleared
calprotectin tests currently available demonstrates that
these tests all offer good clinical sensitivity (≥87.6%)
and can therefore correctly identify patients with IBD.
However, there are notable performance shortfalls with
regard to clinical specificity and the overall clinical utility
scores of many of these same assays.
Comparing Clinical Specificity
The clinical specificities of the FDA 510(k) cleared fecal
calprotectin tests vary greatly, ranging from 66.8%
-95.1%.11 The fecal calprotectin tests with low clinical
specificity have high false positive rates.11 This leads to an
increased number of patients with IBS reported to have
levels of calprotectin indicative of IBD (false positives) and
leading to unnecessary follow-up colonoscopies.1 Research
in this field has suggested that the clinical specificity of
several of these calprotectin tests would be improved if the
positive cut-off values were to be increased.9,12 However,
this would in turn sacrifice clinical sensitivity and increase
the chance of false negative results in patients with IBD,
thereby lowering the utility of a fecal calprotectin screen.9,12
Comparing Clinical Utility of Calprotectin Tests
The calculated clinical utility scores (Tables 1 & 2) from four
of the eight FDA cleared calprotectin tests are lower than
the standard benchmark of 170, indicating that these tests
offer sub-optimal clinical utility to gastroenterologists and
their patients. These same calprotectin assays exhibit the
highest false positive rates. Therefore, clinical laboratories
running these calprotectin tests are are more likely to report
results that may misguide decisions made by ordering
physicians.
 4

False AMR from

Date of FDA 510(k) Clinical Clinical Clinical Clinical
Applicant Test Name Positive Primary
Clearance Number Accuracy Sensitivity Specificity Utility
Rate Dilution (µg/g)
Genova PhiCal™ Test 4/26/2006 K050007 15.6 – 250
®
Eurospital S.p.A. Calprest 1/16/2014 K130945 15.6 - 500
Information not available
Eurospital S.p.A. Calprest® NG 11/10/2016 K160447 27.1 - 3000
QUANTA Flash®
Inova Diagnostics, Inc. 12/22/2017 K170993 16.1 - 3500
Calprotectin
®
BÜHLMANN BÜHLMANN fCAL ELISA 6/4/2018 K181012 83.0% 93.3% 72.3% 164.6 27.7% 30 - 1800
DiaSorin, Inc. LIAISON® Calprotectin 12/26/2018 K182698 85.2% 98.0% 65.7% 163.7 34.3% 5 - 800

BÜHLMANN BÜHLMANN fCAL® turbo 6/25/2019 K190784 83.8% 91.1% 76.2% 167.3 23.8% 30 - 3000
ALPCO Calprotectin
ALPCO 10/25/2019 K191807 93.9% 92.1% 95.1% 187.2 4.9% 7.9 - 6000
Chemiluminescence ELISA

Table 1: Summary of clinical performance when assessing devices based on their ability to differentiate between IBD and IBS.

False AMR from

Date of FDA 510(k) Clinical Clinical Clinical Clinical
Applicant Test Name Positive Primary
Clearance Number Accuracy Sensitivity Specificity Utility
Rate Dilution (µg/g)
Genova PhiCal™ Test 4/26/2006 K050007 82.4% 87.6% 79.3% 166.9 20.7% 15.6 – 250
®
Eurospital S.p.A. Calprest 1/16/2014 K130945 93.5% 96.9% 85.0% 181.9 15.0% 15.6 - 500
®
Eurospital S.p.A. Calprest NG 11/10/2016 K160447 92.3% 94.6% 90.2% 184.8 9.8% 27.1 - 3000
QUANTA Flash®
Inova Diagnostics, Inc. 12/22/2017 K170993 81.8% 96.5% 74.1% 170.6 25.9% 16.1 - 3500
Calprotectin
®
BÜHLMANN BÜHLMANN fCAL ELISA 6/4/2018 K181012 79.5% 93.3% 70.3% 163.6 29.7% 30 - 1800
®
DiaSorin, Inc. LIAISON Calprotectin 12/26/2018 K182698 81.3% 98.0% 66.8% 164.8 33.2% 5 - 800
BÜHLMANN BÜHLMANN fCAL® turbo 6/25/2019 K190784 81.0% 91.1% 74.3% 165.4 25.7% 30 - 3000
ALPCO Calprotectin
ALPCO 10/25/2019 K191807 92.5% 92.1% 92.5% 184.6 7.5% 7.9 - 6000
Chemiluminescence ELISA

Table 2: Summary of clinical performance when assessing devices based on their ability to diagnose IBD.

Conclusion
A thorough review of the clinical performance
characteristics of all of the FDA cleared fecal calprotectin
tests currently available to clinicians and reference
laboratories demonstrates that all assays have different
levels of accuracy and utility when screening levels of
calprotectin in patients suspected of having IBD (Tables
1 & 2). When making the decision as to which test should
be implemented for assessing levels of fecal calprotectin, it
is important to understand all of the clinical characteristics of
each assay and how they impact the patient. In line with the
intended use statement for all eight cleared devices, the
criteria for a good fecal calprotectin test are twofold. First and
foremost, IBD patients must be positively identified at the
same time that IBS patients are ruled out, so as to eliminate
unnecessary follow up endoscopic procedures. Secondarily,
IBD patients must also be positively identified, while non-IBD
patients are ruled out. When all of these requirements are
met, this ensures that physicians are provided with the most
accurate information to assist them in making the correct
diagnosis for their patients.

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