2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

Telemedicine for follow-up of systemic lupus erythematosus during the 2019 coronavirus pandemic: A pragmatic randomized controlled trial

INTRODUCTION

Patients with systemic lupus erythematous were vulnerable to severe coronavirus disease 2019 infection and the negative impact of disrupted healthcare delivery. Telemedicine has been a popular alternative to standard in-person care during the pandemic despite the lack of evidence.

METHODS

This was a 1-year pragmatic randomized-controlled trial. Patients followed at the lupus nephritis clinic were randomized to either telemedicine or standard follow-up in a 1:1 ratio. Patients in the telemedicine group were followed up via videoconferencing. Standard follow-up group patients continued conventional in-person outpatient care. The primary outcome of the study was the proportion of patients in low disease activity after 1 year. Secondary outcomes included cost-of-illness, safety, and various patient-reported outcomes.

RESULTS

From 6/2020 to 12/2021, 144 patients were randomized and 141 patients (telemedicine: 70, standard follow-up: 71) completed the study. At 1 year, 80.0% and 80.2% of the patients in the telemedicine group and standard follow-up group were in lupus low disease activity state or complete remission, respectively (p = 0.967). Systemic lupus erythematous disease activity indices, number of flares and frequency of follow-ups were also similar. There were no differences in the cost-of-illness, quality of life or mental health scores. However, significantly more patients in the telemedicine group (41.4% vs 5.6%; p < 0.001) required switch of mode of follow-up and higher proportion of them had hospitalization during the study period (32.9% vs 15.5%; p = 0.016). Being in the telemedicine group or not in low disease activity at baseline were the independent predictors of hospitalization (odds ratio: 2.6; 95% confidence interval: 1.1-6.1, odds ratio: 2.7, 95% confidence interval: 1.1-6.7, respectively) in the post hoc analysis.

CONCLUSIONS

In patients with systemic lupus erythematous, telemedicine predominant follow-up resulted in similar 1-year disease control compared to standard care. However, it needed to be complemented by in-person visits, especially in patients with unstable disease.

Risk factors associated with thrombocytopenia in systemic lupus erythematosus: A systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) frequently manifests with thrombocytopenia (TP), a hematologic complication that heightens the risk of severe outcomes and increases mortality. This meta-analysis aims to evaluate the potential risk factors associated with TP in SLE patients, providing insights into the demographic features, clinical features, and laboratory findings that contribute to this condition.

METHODS

A comprehensive literature search was conducted across eight databases from inception to September 1, 2024. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis was conducted using univariate and multivariate analyses with Revman 5.3, while heterogeneity was addressed through subgroup and sensitivity analyses. Publication bias was assessed using funnel plots and Egger tests via Stata 15.0.

RESULTS

Seventeen high-quality studies meeting the inclusion criteria were incorporated into this meta-analysis. Independent risk factors for TP in SLE included age (Demographic Features), serositis, splenomegaly, blood system involvement, and renal involvement (Clinical Features), as well as cardiac involvement, anemia, leukocytopenia, low C3/C4, ACA, and CRP (Laboratory Findings). Arthritis and rash were protective factors. Subgroup analysis addressed heterogeneity caused by unit and sample size differences. Sensitivity analysis comparing the consistency between fixed-effects model (FEM) and random-effects model (REM) confirmed the reliability of the findings, and both funnel plots and Egger tests suggested no publication bias.

CONCLUSION

This meta-analysis identified several potential independent risk factors for TP in SLE. Early screening and timely intervention for patients with these risk factors are essential to reduce the likelihood of TP, prevent severe organ damage, and improve overall prognosis.

Neutrophil extracellular traps as a potential marker of systemic lupus erythematosus activity

BACKGROUND

The heterogeneity of systemic lupus erythematosus (SLE) poses a significant challenge in identifying biomarkers for assessing disease activity. Currently, there is a paucity of established biomarkers capable of evaluating SLE flares. This study aimed to identify novel biomarkers that exhibit improved diagnostic accuracy in assessing SLE activity.

METHODS

A cross-sectional study was conducted at Zhongshan Hospital Xiamen University from August 2021 to April 2024,enrolling 118 patients with SLE, including 81 cases of active SLE, 50 cases of active lupus nephritis (LN) and 30 cases of active non-LN. The objective was to evaluate the diagnostic accuracy of novel biomarker called Neutrophil Extracellular Traps(NETs) for SLE activity and analyze its correlations with conventional biomarkers such as complement C3, C4, and anti-dsDNA.

RESULTS

Serum NETs levels were significantly elevated in patients with active SLE and active LN(P < 0.001). Furthermore, positive correlations were observed between NETs levels and disease activity score based on Systemic Lupus Erythematosus Disease Activity Index-2 K (SLEDAI-2 K) (r = 0.64, P < 0.001), as well as anti-dsDNA antibody (r = 0.54, P < 0.001).Conversely, the NETs levels were negativity correlated with complement C3 concentration (r = -0.50, P < 0.001), as well as C4 concentration (r = -0.34,P < 0.001). Univariate and multivariate analysis revealed two biomarkers performed statistical significance: NETs (OR = 6.802, 95 %CI: 2.414-19.167,P < 0.001) and anti-dsDN A(OR = 3.95,95 %CI:1.582-9.864, P = 0.003). NETs had the highest AUC of 0.82(P < 0.001), with a cut-off at 515.47 ng/L demonstrating 61.63 % sensitivity and 96.87 % specificity. For the active LN group, the AUC was found to be 0.97 (P < 0.001), with a cutoff value of 515.47 ng/L, sensitivity of 100 %, and specificity of 59.76 %. Moreover, the active non-LN group had AUC of 0.70 (P = 0.007), with the same cutoff value, sensitivity of 89.61 %, and specificity of 51.61 %.

CONCLUSION

In contrast to conventional laboratory markers, serum NETs represent a novel diagnostic marker for assessing disease activity in SLE, demonstrating promising potential for clinical application.

Cardiovascular disease risk in Korean patients with systemic lupus erythematosus compared to diabetes mellitus and the general population

To evaluate the incidence and risk of cardiovascular disease (CVD) among Korean patients with systemic lupus erythematosus (SLE) comparing them to diabetes patients and the general population. This nationwide cohort study focused on incident SLE patients aged over 40 years, matched with diabetes patients and the general population (1:4:4 ratio). CVD was defined as ischaemic heart disease, ischaemic stroke, and cardiac arrest. Incidence rate and incidence rate ratio (IRR) of CVD were calculated using generalised estimating equation models. The Fine-Gray model assessed risk factors for CVD in both SLE and diabetes patients. The study included 4272 incident SLE patients, 17,003 diabetes patients, and 17,088 from the general population. SLE patients had higher CVD risk compared to the general population, with adjusted IRRs of 1.99 for overall CVD. Diabetes patients showed increased CVD risk, but to a lesser extent, with an IRR of 1.39. SLE patients aged 40-59 years displayed a significantly elevated CVD risk. Advanced age, male gender, and current use of glucocorticoids, immunosuppressive, and anti-platelet agents were associated with increased CVD risk in SLE patients. SLE patients have a higher risk of CVD compared to the general population, more so than diabetes patients.

Real-world treatment patterns and clinical characteristics in patients with moderate-to-severe systemic lupus erythematosus: an analysis of the SLE Prospective Observational Cohort Study (SPOCS)

OBJECTIVES

Systemic lupus erythematosus (SLE) is a disease with heterogeneous treatment patterns largely based on organ involvement and disease severity. The SLE Prospective Observational Cohort Study (SPOCS) collected data worldwide over 3 years from patients with moderate-to-severe SLE. We report real-world patterns of medication use in patients enrolled in SPOCS.

METHODS

Data were collected at study entry; patients were followed twice annually according to local practice. Disease activity (SLE Disease Activity Index 2000 (SLEDAI-2K)), average oral glucocorticoid dose and use of other treatments-specifically antimalarials, biologics and immunosuppressants-were measured over time. Subgroup analyses were stratified by baseline interferon gene signature (IFNGS) status and disease activity (SLEDAI-2K) status.

RESULTS

Patient demographics and baseline characteristics were similar among subgroups; the majority of patients were on antimalarials (n=670; 81.1%), followed by glucocorticoids (n=537; 65.0%), immunosuppressants (n=453; 54.8%) and biologics (n=175; 21.2%). In the overall population, median (IQR) SLEDAI-2K scores decreased within 12 months (baseline: 8.0 (6.0-12.0); 12 months: 4.0 (2.0-8.0)) and remained stable thereafter. The mean (SD) daily oral glucocorticoid dose increased by 6 months (baseline: 6.0 (7.09); 6 months: 9.8 (8.67)) and remained stable thereafter. The proportion of patients who were on glucocorticoid doses >5 mg/day ranged from ~20% to 33% throughout the study. In subgroup analyses, patients with high IFNGS and high disease activity state (HDAS) at baseline used more immunosuppressants and glucocorticoids compared with those with low IFNGS and non-HDAS at baseline.

CONCLUSIONS

These findings underscore that SLE therapy is still often unable to reach goals as recommended by the European Alliance of Associations for Rheumatology, both with regard to glucocorticoid use and disease activity, suggesting that there is an unmet need for new treatment options for patients with SLE.

TRIAL REGISTRATION NUMBER

NCT03189875; 16 June 2017.

Lactobacillus rhamnosus LC-STH-13 ameliorates the progression of SLE in MRL/lpr mice by inhibiting the TLR9/NF-κB signaling pathway

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease often treated with glucocorticoids, which can lead to complications such as osteoporosis and an increased infection risk. Hence, identifying safe and effective treatment strategies is crucial. Lactobacillus has shown promise in improving immune disorders. We investigated Lactobacillus rhamnosus LC-STH-13 for its probiotic properties. Female MRL/lpr mice, prone to lupus, were used to assess its impact on SLE development. The results showed that the intervention with L. rhamnosus LC-STH-13 significantly reduced the level of circulating anti-autoantibodies (p < 0.05) and rebalanced Th17/Treg cells (p < 0.05). Kidney tissue analysis revealed reduced immune cell infiltration and immune complex deposition in glomeruli. L. rhamnosus LC-STH-13 mitigated kidney inflammation via the TLR9/NF-κB pathway (p < 0.05) and attenuated complement-induced renal damage (p < 0.05). Furthermore, 16S rRNA sequencing data analysis indicated that L. rhamnosus LC-STH-13 can restore intestinal microecological imbalance caused by the development of SLE. These findings suggested that L. rhamnosus LC-STH-13 improves the development of SLE by regulating the TLR9/NF-κB pathway and intestinal microbiota, offering a foundation for exploring safe and effective treatments.

Downregulation of ferroptosis-related ATF3 alleviates lupus nephritis progression

BACKGROUND

The role of ferroptosis in lupus nephritis (LN) is unclear. This study aimed to explore the effects of ferroptosis-related genes in LN through bioinformatics prediction and experimental validation.

METHODS

Sample data were collected from the GEO dataset and divided into glomeruli and tubulointerstitium. We collected 382 ferroptosis-related genes. The intersection of ferroptosis-related genes with glomeruli and tubulointerstitium data, respectively, was performed. Machine learning methods (including unsupervised cluster typing and random forests) were operated to identify ferroptosis subtyping and ferroptosis important genes in LN. Immune infiltration and functional analysis were performed. The expression of ferroptosis important gene ATF3 was validated in vivo and in vitro.

RESULTS

6 ferroptosis important genes common to glomeruli and tubulointerstitium were screened, including ATF3, CD44, CYBB, JUN, NCF2, and NNMT. ATF3 decreased in the LN group compared to the Control. Silencing ATF3 mitigated LPS/erastin-induced ferroptosis. Functional analysis showed that ATF3 was markedly enriched in the interferon-gamma-mediated signaling pathway, ECM-receptor interaction, and cell adhesion. In glomeruli, T cells regulatory (Tregs) infiltration decreased and Macrophages M1 levels increased with elevated ATF3 expression. Levels of immune cell infiltration were altered in different ferroptosis subtypes of LN glomeruli and tubulointerstitium.

CONCLUSIONS

Ferroptosis-related ATF3 levels decreased in LN. Inhibition of ATF3 might alleviate LN development by affecting the macrophage M1 and Treg cell infiltration. These implied that ATF3 might be a potential target for developing LN therapeutic strategies.

EXamining the feasibility of exerCisE to manage symptoms of Lupus (EXCEL): a protocol for a randomised controlled pilot study

INTRODUCTION

SLE is a chronic autoimmune disease that results in sustained hyperactivation of innate and adaptive immune cells and widespread inflammatory damage. Regular exercise reduces SLE symptoms including fatigue and joint pain and improves patient quality of life. However, most individuals with SLE are not sufficiently active to achieve these benefits, and guidance on the optimal approach to exercise is limited. EXCEL will examine the feasibility of conducting a large-scale randomised controlled trial comparing the effects of a remotely monitored, home-based, exercise programme with standard of care for individuals with SLE.

METHODS AND ANALYSIS

30 females with SLE will be recruited, and those randomised into Exercise (SLE-Ex) will codesign a progressive training plan with support from the research team. The aim of each 12-week plan will be to complete 150 min of moderate (60-70% heart rate max, HRmax) or 90 min of vigorous exercise (>70% HRmax) per week. SLE-Ex will be encouraged to exercise independently (without support) from weeks 13-18. Participants with SLE that are randomised into Control (SLE-Con) will maintain habitual activity without support for 18 weeks. Measures of feasibility and acceptability will be reported, and peripheral blood will be collected at weeks 0, 12 and 18 to explore whether the frequency, phenotype and metabolic profile of lymphocyte subsets has changed. Biomarkers of SLE activity, and self-reported measures of fatigue, sleep quality and health-related quality of life will also be monitored at these timepoints. Blood and self-reported measures will be compared with a healthy control (HC) group (n=15, age and body mass index matched) at baseline only.

ETHICS AND DISSEMINATION

A favourable ethical opinion was given by South East Scotland Research Ethics Committee (22/SS/0082). Findings will be disseminated at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN72757645.

Cardiovascular profile of systemic lupus erythematosus patients hospitalized for COVID-19 in Spain: Analysis of the SEMI-COVID-19 Registry

BACKGROUND

Despite advancements in understanding the interplay between systemic lupus erythematosus (SLE), cardiovascular disease and COVID-19, challenges and knowledge gaps persist. This study aimed to characterize the cardiovascular profiles of SLE patients hospitalized with COVID-19 and to evaluate the influence of SLE on the development of cardiovascular complications.

METHODS

This was a multicentre, nationwide observational study in which data were sourced from the SEMI-COVID-19 Registry between March 1, 2020, and March 31, 2021, involving 150 Spanish hospitals. SLE patients were matched with non-SLE patients based on sex, age, and hospitalization date.

RESULTS

Of the 20,970 patients included in the SEMI-COVID-19 Registry, 38 were previously diagnosed with SLE. The non-SLE group was composed of 103 patients. The mean age of the SLE patients was 63 years, with 81.6% females and 21.1% non-European patients. SLE patients exhibited a significantly higher frequency of chronic kidney disease (14.4% vs 2.9%; p=0.004), stroke (23.7% vs 2.9%; p<0.001), and increased use of cardiovascular medications. SLE demonstrated an independent association with the occurrence of major cardiovascular events (MACE) (OR: 3.934; 95% CI: 1.247-12.432).

CONCLUSIONS

SLE patients hospitalized for COVID-19 are at high risk of having an unfavorable baseline cardiovascular profile and are more prone to MACEs and adverse noncardiovascular outcomes during hospitalization.

Real-world effectiveness of intravenous belimumab in adults with systemic lupus erythematosus: results of the observational OBSErve study in the Russian Federation

BACKGROUND

The real-world effectiveness of intravenous (IV) belimumab in treating systemic lupus erythematosus (SLE) has been demonstrated in various countries through the OBSErve (evaluation Of use of Belimumab in clinical practice SEttings) program. Here we describe the clinical effectiveness of IV belimumab for treating SLE in real-world clinical practice in the Russian Federation.

METHODS

In the retrospective, observational OBSErve Russia study (GSK Study 215349), eligible physicians enrolled adults with SLE receiving IV belimumab as part of their standard care. De-identified data were collected from patient medical records from September 2021 to March 2022. The primary outcome was the physician-assessed overall clinical response at 6 months post-index versus index (belimumab initiation) among patients receiving belimumab for ≥6 months. Other endpoints included change in Safety of Estrogens in Lupus Erythematosus National Assessment - SLE Disease Activity Index (SELENA-SLEDAI) score and glucocorticoid use.

RESULTS

Overall, 59 patients initiated IV belimumab, mainly due to the previous regimen not being effective and to decrease glucocorticoid use (76.3% each); 15.3% of patients started belimumab within the first year of SLE diagnosis. Only 13.6% of patients discontinued belimumab within the first 6 months, mainly due to loss to follow-up and loss of insurance/reimbursement. At 6 months post-index, among patients who completed ≥6 months of belimumab therapy (full analysis set, n = 53), 90.6% and 60.4% had an overall clinical improvement of ≥20% and ≥50%, respectively. Mean (standard deviation, SD) change in SELENA-SLEDAI score from index to 6 months post-index was -5.9 (4.3). Mean (SD) glucocorticoid dose decreased from 12.2 (7.3) mg/day at index to 8.6 (5.1) mg/day at 6 months post-index (n = 50).

CONCLUSIONS

Patients with SLE receiving IV belimumab for 6 months in real-world settings in the Russian Federation experienced overall clinical improvements and reductions in glucocorticoid use, which is an important long-term strategy of SLE treatment.

Subtype and Racial Erythema Variation for Cutaneous Lupus Trials

Importance

Regulatory guidance and standardization of disease outcome measures are essential to improve cutaneous lupus erythematosus (CLE) trial design and enhance the diversity of trial participants.

Objective

To assess variability in erythema presentation across CLE subtypes and among race and ethnicity groups to determine whether these potential differences affect patient eligibility for erythema trials.

Design, Setting, and Participants

This cross-sectional study included 377 patients with CLE enrolled in the University of Pennsylvania Cutaneous Lupus Erythematosus Database from January 2007 to December 2023. Data analyses were performed from December 2023 to February 2024.

Exposure

Race and CLE subtype.

Main Outcomes and Measures

Mean erythema calculated per the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI)-Activity total score divided by areas affected; then, the result was categorized as pink (1.00-1.49) or red (≥1.50) as surrogate estimates of scores per the Cutaneous Lupus Activity Investigator Global Assessment (CLA-IGA).

Results

The total study cohort included 377 adult patients with CLE (mean [SD; range] age, 45.2 [14.8; 18.4-88.8] years; 305 females [80.9%] and 72 males [19.1%]; 115 Black [30.5%], 228 White [60.5%], 34 patients of other races [9.0%; Asian, multiple races, Native American/Pacific Islander, or unknown], and 11 of Hispanic/Latino ethnicity [2.9%]). The most common CLE subtype was chronic CLE (CCLE), affecting 243 patients (64.5%), followed by subacute CLE (SCLE) in 103 patients (27.3%) and acute CLE (ACLE) in 31 patients (8.2%). Significant differences were observed in average erythema across subtypes, with mean (SD) SCLE of 1.62 (0.39) and hypertrophic CCLE of 1.78 (0.25) as the only subtypes routinely classified as red. Significant differences were also observed by race and ethnicity: mean (SD) erythema score in White patients was red (1.58 [0.45]) more frequently than in Black patients (1.36 [0.40]) and patients of other races (1.30 [0.39]), in whom, on average, it was scored as pink. Importantly, among patients who would meet typical CLASI entry criteria (score ≥8) for clinical trials, erythema in more Black patients than in White patients was classified as pink (42% [96 patients] vs 24% [28 patients]), which suggests exclusion from trial participation when a baseline of red lesions is required.

Conclusions and Relevance

The findings of this cross-sectional study suggest that using average erythema scores per the CLA-IGA scale imposes substantial limitations on trial eligibility, specifically by race and subtype. Given the critical need to standardize CLE trial outcome measures and increase diverse representation in clinical trials, our findings support the use of the CLASI as the primary scoring tool to determine erythema trial eligibility.

Anti-retinal Autoantibodies in Hydroxychloroquine Eye Toxicity

OBJECTIVE

Autoimmune retinopathy and hydroxychloroquine (HCQ)-related retinal toxicity share many similarities, raising the possibility autoimmunity plays a role in HCQ retinopathy. The objective of this study is to determine whether patients diagnosed with HCQ retinal toxicity are more likely to have circulating antiretinal autoantibodies (AAbs) compared to controls.

METHODS

We tested plasma samples for the presence of anti-retinal AAbs by immunoblotting in 270 patients with systemic lupus erythematosus (SLE) receiving HCQ. We then evaluated for the presence of HCQ retinal toxicity and other baseline risk factors for HCQ toxicity through chart review. Frequency of specific anti-retinal AAbs in patients with HCQ retinal toxicity was compared to those with no retinal toxicity via multivariate logistic regression.

RESULTS

Patients with HCQ retinal toxicity had a higher likelihood of testing positive for anti-arrestin AAbs (60.7% vs 30.6%, P = 0.001) and anti-pyruvate kinase M2 AAbs (46.4% vs 28.1%, P = 0.05). Patients with HCQ eye toxicity also had a higher number of total anti-retinal AAbs (mean 3.0 ± 2.40 vs 2.04 ± 1.7, P = 0.01). In multivariate analysis accounting for risk factors associated for HCQ eye toxicity, the presence of anti-arrestin antibodies was associated with a 3.2-fold increase in the odds of developing HCQ eye toxicity.

CONCLUSION

Anti-retinal AAbs were more common in patients with SLE with HCQ retinal toxicity. When controlling for risk factors associated with HCQ toxicity, anti-arrestin AAbs were associated with increased odds for the development of eye toxicity, suggesting a potential role for anti-retinal AAbs as a biomarker of HCQ eye toxicity.

Sex-specific cut-off for dilute Russell's viper venom time lupus anticoagulant test may be of value

Background

Current guidelines recommend application of the 99th percentile to determine the cut-off value on at least 120 healthy donors regardless of sex for lupus anticoagulant (LA) ratio of each step. However, a statistically significant difference between the sexes has been found for LA ratio recently.

Objectives

To clarify whether this sex difference in dilute Russell's viper venom time (DRVVT) exists in various detection systems and the necessity of setting sex-specific cut-off values.

Methods

Blood samples from healthy donors were detected on 3 DRVVT detection systems, and the sex-specific cut-offs of DRVVT test were obtained based on the 99th or 97.5th centile of screen, confirm, and normalized ratios (NRs) grouped by sex in each system. One thousand one hundred twenty one female patients with suspected antiphospholipid syndrome (APS) were retrospectively investigated, the APS-associated clinical and laboratory characteristics of female patients stratified by different cut-offs of DRVVT ratio were compared.

Results

The DRVVT NRs of females were significantly lower than those of males on each system. The female patients with DRVVT NR between female-specific and regardless of sex cut-offs had higher positive rates of silica clotting time test and LA retest results after 12 weeks than those with DRVVT NRs lower than female-specific cut-off, there were also more patients who met the APS clinical criteria.

Conclusion

The sex difference of the cut-off value for DRVVT LA test is confirmed on multiple systems, the female-specific cut-off is lower than regardless of sex cut-off and may lead to more female patients being considered as high-risk population for APS.

SLE inflammatory musculoskeletal abnormalities, confirmed by MRI, show a specific profile with a worse health-related quality of life

OBJECTIVES

To determine if there is a clinicodemographic or serological profile associated with MRI-confirmed inflammatory musculoskeletal abnormalities in SLE patients. To investigate the relationship between these alterations and HRQoL.

METHODS

patients with SLE from our previous study in whom a wrist and hand MRI with contrast was performed were included. Sociodemographic, clinical, therapeutic, serological data and PROs were collected and correlated with MRI findings.

RESULTS

83 patients were analysed. Erosions and synovitis were more common in older patients (55 ± 12.61 vs 45.06 ± 12.18 years, p .001, 52.78 ± 12.99 vs 44.95 ± 12.49 years, p .011). Synovitis was less frequent in patients with nephritis (6.7% vs 24.3%, p .031). Treatment received showed some associations: patients with bone edema received more methotrexate (25% vs 6.3%, p .033), those with erosions and peritendonitis received less mycophenolic acid (5.6% vs 22.9%, p .034; 0% vs 12.8%, p .026). Peritendonitis correlated with higher SLEDAI-2K (7 ± 2.45 vs 3.64 ± 3.34, p .018).

WORSE HAQ

Patients with synovitis, tenosynovitis, peritendonitis and bone edema reported higher pain (6.03 ± 2.57 vs 4.26 ± 2.49, p .005; 6.56 ± 1.95 vs 4.76 ± 2.75, p .017; 8.80 ± 1.30 vs 4.95 ± 2.55, p .001; 6.47 ± 2.62 vs 4.83 ± 2.58, p .026, respectively). Patients with synovitis reported higher fatigue numerical values (2.32 ± 0.82 vs 1.91 ± 0.84, p .035), with tenosynovitis worse FSS-9 (61.50 ± 1.73 vs 45.70 ± 16.80, p .015), and with both synovitis and peritendonitis worse HAQ (1.14 ± 0.69 vs 0.75 ± 0.65, p .031; 1.69 ± 0.07 vs 0.90 ± 0.69, p .018).

CONCLUSION

SLE patients with confirmed musculoskeletal alterations on MRI were generally older, less likely to have lupus nephritis, and received different treatments. They reported a worse HRQoL in terms of pain, fatigue and functional disability.

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus

OBJECTIVE

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia.

METHODS

This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/ statements.

RESULTS

A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence.

CONCLUSION

This Saudi National Clinical Practice guidelines for SLE management provide evidence- based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Immune thrombocytopenia in patients with systemic lupus erythematosus

Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The diversity of its clinical features and treatment responses may reveal the complex pathophysiological mechanisms of the disease. To enhance the therapeutic response rate and improve the prognosis for SLE patients with concurrent ITP, while reducing adverse events during the treatment process, it is crucial to accurately identify and apply clinical parameters to predict patients' responses to treatment. In addition to conventional therapeutic approaches such as glucocorticoids, immunosuppressants, and intravenous immunoglobulin (IVIG), a range of emerging therapies are gradually becoming the focus of research. These innovative therapeutic strategies include thrombopoietin receptor agonists (TPO-RAs), targeted therapies against B-cells, and plasma cell-targeted treatments. With a deepening understanding of the role of platelets in immune and inflammatory responses, novel platelet-targeted therapeutic agents in the field of SLE-ITP treatment may demonstrate significant potential. Despite this, to ensure the clinical efficacy and safety of these therapeutic approaches, we must rely on rigorously designed randomized controlled trials (RCTs) for further validation. This article provides a systematic review of the pathogenesis of systemic lupus erythematosus (SLE) complicated by immune thrombocytopenia (ITP) and conducts a comprehensive overview of current treatment strategies. The article also provides an in-depth exploration of the key biomarkers that may influence the therapeutic response in SLE-ITP patients. This comprehensive analysis aims to elucidate the factors that potentially affect the efficacy of treatments and contribute to a more personalized approach to patient care.

The 100 top-cited studies in systemic lupus erythematosus: A bibliometric analysis

Systemic lupus erythematosus (SLE) is an autoimmune inflammatory tissue disease. In view of the explosive growth in research on SLE, bibliometrics was performed to evaluate the 100 top-cited papers in this realm. We performed the search with terms "systemic lupus erythematosus" the Web of Science Core Collection database on May 3, 2023. Relevant literatures were screened. Data were extracted and analyzed by SPSS. The citations of 100 top-cited SLE studies spanned from 472 to 13,557. Most studies (60 out of 100) were conducted in the United States. Total citation times were positively associated with ACY, which was negatively correlated with the length of time since publication. Approximately half of the studies focused on the underlying mechanisms of SLE. New biologic therapies garnered attention and development. Our findings provide valuable insights into the developments in crucial areas of SLE and shed contributions to future studies.

Fine-tuning SLE treatment: the potential of selective TYK2 inhibition

In systemic lupus erythematosus (SLE), adaptive immunity is activated by the stimulation of innate immunity, leading to the development of autoreactive T cells and activation and differentiation of B cells. Cytokine signalling plays an essential role in the pathogenesis and progression of this disease. In particular, the differentiation and function of CD4+ T cell subsets, which play a central role in SLE pathology, are significantly altered by cytokine stimulation. Many cytokines transmit signals via the Janus-activated kinase (JAK)-STAT pathway, but there is no one-to-one correspondence between cytokine receptors and JAK/TYK2. Multiple cytokines activate JAK/TYK2, and multiple JAK/TYK2 molecules are simultaneously activated by a single cytokine. Therefore, the modulation of the JAK-STAT pathway has the potential to control immune responses in SLE. Although several JAK/TYK2 inhibitors are currently undergoing clinical trials, more selective drugs that can target cytokine signals according to the specific pathology of the disease are required. TYK2 inhibitors, which are involved in the signal transduction of type I interferon and interleukin-12/23 pathways and are linked to disease susceptibility genes in SLE, may have the potential to fine-tune the differentiation and function of immune cells, particularly CD4+ T cells.

Exploring potential multiple molecular biomarkers that predict treatment response in patients with lupus nephritis

Limited knowledge exists regarding biomarkers that predict treatment response in Lupus nephritis (LN). We aimed to identify potential molecular biomarkers to predict treatment response in patients with LN. We enrolled 66 patients with active LN who underwent renal biopsy upon enrollment. Serum and urine samples were collected longitudinally, and we measured 12 biomarkers in each sample using a multiplex immunofluorescence assay. These biomarkers included monocyte chemoattractant protein-1 (MCP-1), interferon gamma-induced protein 10 (IP-10), interferon-γ (IFN-γ), interleukin 6 (IL-6), interleukin 16 (IL-16), interleukin 17 (IL-17), interleukin 23 (IL-23), tumor necrosis factor receptor II (TNF-RII), vascular cell adhesion molecule 1 (VCAM-1), retinol-binding protein 4 (RBP 4), vitamin D binding protein (VDBP), and neutrophil gelatinase-associated lipocalin (NGAL). Patients were categorized into two groups based on their 1-year treatment response to Mycophenolate mofetil (MMF)-based therapy: 50 responders and 16 non-responders. Only urine IL-17 (uIL-17) showed baseline level differences between the two groups, with higher in responders. In ROC curve analyses assessing the predictive performance of biomarkers, baseline uIL-17 and changes in uIL-6 and uIL-23 levels at 3 months could predict the 1-year treatment response, showing AUC values of 0.70 (95% CI 0.54-0.87), 0.70 (0.54-0.86), and 0.71 (0.57-0.85), respectively. Combining uIL-6 and uIL-23 into a model improved predictability, achieving an AUC of 0.75 (0.61-0.90). Baseline uIL-17 levels and early changes in uIL-6 and uIL-23 could serve as potential biomarkers to predict 1-year treatment response in lupus nephritis patients receiving MMF-based therapy.

Relation between hydroxychloroquine dose and continuation rate in patients with systemic lupus erythematosus

OBJECTIVES

Hydroxychloroquine (HCQ) is recommended at a target dose of 5 mg/kg per actual body weight to reduce the risk of retinopathy in systemic lupus erythematosus (SLE). However, the efficacy of HCQ has been established at doses of 6.5 mg/kg per ideal body weight. This study aimed to clarify the effects of the HCQ dose on the continuation rate in Japanese patients, who generally have a lower body mass index than Western patients.

METHODS

This retrospective single-centre observational study enrolled patients with SLE on HCQ therapy. Patients were divided into two groups with a dose per actual body weight [the low-dose (<5 mg/kg) group and the high-dose (≥5 mg/kg) group], and continuation rates were compared. The efficacy of 1-year HCQ therapy was assessed in patients without additional immunosuppressive agents and biologics.

RESULTS

Of the 231 patients enrolled, 48 (20.8%) discontinued HCQ. The HCQ dose per actual body weight was identified as an independent risk factor for discontinuation. The low-dose group showed a significantly higher 1-year HCQ continuation rate than the high-dose group (83.2% vs. 72.8%, respectively). Both groups showed reductions in glucocorticoid requirement and serological activity after 1-year HCQ therapy.

CONCLUSIONS

HCQ <5 mg/kg per actual body weight may facilitate greater continuation.

Real-world treatment patterns, healthcare resource utilisation and costs in patients with SLE in the USA

OBJECTIVE

To evaluate the treatment patterns, medication adherence, concomitant corticosteroid use, factors influencing sequence of therapies (SOTs), healthcare resource utilisation (HCRU) and associated costs in adults with SLE in the USA.

METHODS

Claims data from the Merative MarketScan Commercial and Medicare Supplemental Database between 2011 and 2019 were used to identify patients with incident SLE. The date of first claim with SLE was defined as the index date, with a 24-month pre-index and ≥24-month post-index period. Descriptive statistics were used to evaluate patient demographics and baseline clinical characteristics, treatment patterns, adherence, HCRU and cost. Multivariable-adjusted logistic regression models were used to identify factors associated with transition between SOTs.

RESULTS

Overall, 2476 patients received SLE treatment. The mean (SD) age was 46.9 (14.1) years and the mean (SD) follow-up duration was 47.8 (15.7) months. High corticosteroid use was prevalent in all SOTs (≥1 corticosteroid; average dose, 16.8-19.3 mg/day; 50%-60% patients). Antimalarials were most commonly prescribed in SOT 1 (85.7%), and immunosuppressants in SOT 2 and 3 (85.4% and 77.5%, respectively). Transition frequency from SOT 1-2 (38.4%) and SOT 2-3 (16.9%) was influenced by immunosuppressant prescription, concomitant corticosteroid use, sex, severe disease activity, non-persistence and age. Adherence was highest for biologics, followed by antimalarials and immunosuppressants. SLE-related HCRU and associated costs increased with SOT progression (mean (SD) at baseline vs SOT 3, US$19 489 (US$45 336) vs US$23 201 (US$39 628)).

CONCLUSION

SLE treatment regimens with greater adherence and reduced corticosteroid use, HCRU and associated costs are needed.

Fibromyalgia comorbidity in Systemic Lupus Erythematosus patients: assessing impact on quality of life

INTRODUCTION

The prevalence of Fibromyalgia in patients with Systemic Lupus Erythematosus (SLE) is significantly higher compared to the general population. Despite this frequent association, Fibromyalgia remains underdiagnosed and consequently inadequately treated, negatively affecting the quality of life of these patients.

OBJECTIVE

This study aims to evaluate the occurrence of Fibromyalgia and its impact on the quality of life of Brazilian patients with SLE treated at a University Hospital in the state of Paraiba.

MATERIALS AND METHODS

This descriptive, observational, and cross-sectional study included patients with SLE diagnosed according to the 2012 criteria of the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC). The occurrence of Fibromyalgia was assessed using the American College of Rheumatology (ACR) criteria of 1990 and 2010/2011, revised in 2016. Quality of life was evaluated using the Short-Form 36 (SF-36) questionnaire for all patients, while the Fibromyalgia Impact Questionnaire (FIQ) was applied to those diagnosed with Fibromyalgia.

RESULTS

The sample comprised 107 SLE patients, with an average age of 54.1 years (SD:12.1), of whom 95.4% (102) were women. The prevalence of Fibromyalgia among SLE patients was 19.1% (21), all of whom were women with a mean age of 45.6 years (SD 9.6). The SF-36 scores of SLE patients with Fibromyalgia were consistently lower across all eight domains compared to those without Fibromyalgia, indicating a significant negative impact of this comorbidity.

CONCLUSION

These findings are consistent with existing literature, highlighting the significant negative impact of Fibromyalgia on the quality of life of patients with SLE.

CONCLUSION

These findings are consistent with existing literature, highlighting the significant negative impact of Fibromyalgia on the quality of life of patients with SLE.

Clinical characteristics and prognostic factors of COVID-19 in rheumatic patients and their family members: a retrospective study

Background

Patients with rheumatic diseases who receive long-term treatment with steroids, immunosuppressants, or biologics are more susceptible to infection with pathogens than the general population. In order to explore the differences in clinical features and prognosis of Corona Virus Disease 2019 (COVID-19) infection between patients with rheumatic diseases and the general population (family members), a retrospective investigative study was used to analyze the differences between the two populations.

Methods

The study was conducted in 13 Grade A Tertiary hospitals in China to investigate the clinical symptoms and prognostic factors of patients with rheumatic diseases who were infected with COVID-19 for the first time and their families.

Results

A total of 2,889 participants were included in this study, including 1,530 patients with rheumatic diseases and 1,359 family members. In terms of clinical symptoms, the complete recovery time from COVID-19 for patients with rheumatic disease patients was 13 days (8.00, 18.00), which was shorter than that of family members (16 days, 11.00, 20.00). The risk of developing moderate to severe cases of COVID-19 was lower in patients with rheumatic disease than in their family members (OR=0.511, P=0.0026). Compared with non-use of non-steroidal anti-inflammatory drugs (NSAIDs), the risk of developing mild cases of COVID-19 was 0.595 times greater with pre-infection use of NSAIDs (P = 0.0003). The use of glucocorticoids and Chinese herbal decoctions before infection increased the probability of developing mild cases of COVID-19 (OR=1.537, 1.773, P<0.05). The risk of developing moderate to severe cases with disease-modifying anti-rheumatic drugs (DMARDs) used before infection was 0.350 times that without such drugs (P<0.001). In terms of prognosis, compared with family members, the complete recovery time of patients with rheumatic diseases was reduced by 2.241 days on average (P<0.001), and the complete recovery time of patients with mild rheumatism was reduced by 4.178 days on average (P<0.001). There was no significant difference in the complete recovery time from COVID-19 in patients with severe rheumatism compared with their family members (P=0.1672). The use of NSAIDs, glucocorticoids, DMARDs, biologics, Chinese patent medicine, and Chinese herbal decoctions during the infection period could shorten the recovery time of COVID-19 symptoms (P<0.05).

Conclusions

Compared with their family members, patients with rheumatic diseases had milder symptoms after infection with COVID-19, which was related to the use of glucocorticoids, DMARDs, and Chinese herbal decoctions before infection. During the COVID-19 infection phase, the use of NSAIDs, glucocorticoids, DMARDs, biologics, Chinese patent medicine, and Chinese herbal decoctions might shorten the recovery time from symptoms of COVID-19.

Chinese clinical trial registry

ChiCTR2300072679.

Efficacy of initial combination with belimumab in newly diagnosed childhood-onset lupus nephritis: a single-centre historical control study

OBJECTIVE

To explore the efficacy of initial treatment of newly diagnosed childhood-onset lupus nephritis (cLN) with combination of belimumab and either cyclophosphamide, mycophenolate mofetil, tacrolimus or multitargeted therapy.

METHODS

A historical control study was conducted on children aged 5-17 years with newly diagnosed cLN. All patients recruited met the 2012 Systemic Lupus International Collaborating Clinics and/or 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for SLE, and the 2003 International Society of Nephrology/Renal Pathology Society histopathological criteria for LN. The primary endpoint was primary efficacy renal response (PERR) at 12 months, and secondary endpoints included complete renal response (CRR), lupus low disease activity state (LLDAS) and remission (Definitions of Remission in Systemic Lupus Erythematosus (DORIS)) at 12 months, changes of SLE Disease Activity Index (SLEDAI) and dose of glucocorticoid (GC).

RESULTS

A total of 101 patients were included with 38 patients in the belimumab group and 63 patients in the standard immunotherapy group. There were no statistically significant differences between the two groups at baseline. At 12 months, compared with the standard immunotherapy group, more patients in the belimumab group had a higher PERR (97.1% vs 80.0%, χ2=3.965, p=0.046), CRR (94.1% vs 76.6%, χ2=4.679, p=0.031), LLDAS (75.0% vs 18.6%, χ2=27.84, p<0.001) and DORIS (34.4% vs 11.9%, χ2=6.626, p=0.01). The belimumab group had faster and greater reductions in SLEDAI and dose of GC (p<0.05), with a significantly higher proportion of patients with dose of GC ≤7.5 mg/day (82.9% vs 30.4%, χ2=19.737, p<0.001). In the standard immunotherapy group, 4 patients (6.3%) experienced a decline in estimated glomerular filtration rate of 30% or more at 12 months, while no patients in the belimumab group experienced worsening of renal function. There were no serious adverse events reported in two groups, and there was no significant difference in the occurrence of infection between the two groups.

CONCLUSION

This study reported for the first time the effectiveness of combined belimumab therapy in a Chinese cohort of patients with cLN. The strategy of initial combination with belimumab helps achieve treatment targets earlier and faster GC tapering. And initial combination therapy in children with cLN with high disease activity may yield more significant benefits.

What do clinical practice guidelines say about deprescribing? A scoping review

INTRODUCTION

Deprescribing (medication dose reduction or cessation) is an integral component of appropriate prescribing. The extent to which deprescribing recommendations are included in clinical practice guidelines is unclear. This scoping review aimed to identify guidelines that contain deprescribing recommendations, qualitatively explore the content and format of deprescribing recommendations and estimate the proportion of guidelines that contain deprescribing recommendations.

METHODS

Bibliographic databases and Google were searched for guidelines published in English from January 2012 to November 2022. Guideline registries were searched from January 2017 to February 2023. Two reviewers independently screened records from databases and Google for guidelines containing one or more deprescribing recommendations. A 10% sample of the guideline registries was screened to identify eligible guidelines and estimate the proportion of guidelines containing a deprescribing recommendation. Guideline and recommendation characteristics were extracted and language features of deprescribing recommendations including content, form, complexity and readability were examined using a conventional content analysis and the SHeLL Health Literacy Editor tool.

RESULTS

80 guidelines containing 316 deprescribing recommendations were included. Deprescribing recommendations had substantial variability in their format and terminology. Most guidelines contained recommendations regarding for who (75%, n=60), what (99%, n=89) and when or why (91%, n=73) to deprescribe, however, fewer guidelines (58%, n=46) contained detailed guidance on how to deprescribe. Approximately 29% of guidelines identified from the registries sample (n=14/49) contained one or more deprescribing recommendations.

CONCLUSIONS

Deprescribing recommendations are increasingly being incorporated into guidelines, however, many guidelines do not contain clear and actionable recommendations on how to deprescribe which may limit effective implementation in clinical practice. A co-designed template or best practice guide, containing information on aspects of deprescribing recommendations that are essential or preferred by end-users should be developed and employed.

TRIAL REGISTRATION NUMBER

osf.io/fbex4.

Patients achieving low lupus disease activity state, systemic lupus erythematosus disease control or remission showed lower rates of organ damage during longitudinal follow-up: analysis of the Hopkins Lupus Cohort

OBJECTIVE

One key target of treating patients with systemic lupus erythematosus (SLE) is to prevent organ damage. This analysis quantified the association between time spent in four specific SLE low disease activity (LDA) states and organ damage rate.

METHODS

This retrospective real-world data analysis (GSK Study 207168), undertaken to help contextualise the BLISS-BELIEVE clinical trial, included adults with SLE enrolled for≥1 year in the Hopkins Lupus Cohort and treated with standard therapy in a specialist care centre between 1987 and 2019. LDA states (Lupus Low Disease Activity State (LLDAS), disease control, clinical and complete remissions) were defined using SLE Disease Activity Index (SLEDAI)/Physician Global Assessment scores, prednisone-equivalent dose and medication use criteria combinations. Time spent in each LDA state was expressed as a percentage of total follow-up (0%; >0-<25%; 25-49%; 50-74%; ≥75%). Pooled logistic models were used to estimate adjusted rate ratios (aRR) between time spent in LDA states and organ damage rate (assessed using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI)).

RESULTS

Overall, 1632 patients experienced 1246 organ damage events. Follow-up time (calculated from days of follow-up) totalled 9841.1 person-years. At baseline, the mean (SD) SLEDAI score was 2.8 (3.3) and the mean (SD) SDI score was 1.7 (1.9). Organ damage rates were lower in patients who achieved an LDA state versus those who did not. Rates decreased with increasing time spent in each LDA state. Even a small percentage of time (>0-<25% vs 0%) spent in an LDA state was associated with reduced damage (aRR (95% CI): LLDAS, 0.75 (0.61, 0.91); disease control, 0.80 (0.68, 0.93); clinical remission, 0.73 (0.60, 0.88); complete remission, 0.80 (0.68, 0.93)).

CONCLUSIONS

Regardless of definition, achieving and maintaining a low disease activity state was associated with reduced organ damage in patients with SLE.

Efficacy of combining aspirin with hydroxychloroquine in pregnancies at high risk for pre-eclampsia: a prospective, multicentre, open-label, single-arm clinical trial, investigator-initiated study (HUGS study)

INTRODUCTION

The use of hydroxychloroquine (HCQ) during pregnancies complicated by systemic lupus erythematosus or refractory antiphospholipid antibody syndrome has demonstrated a significant ability to prevent pre-eclampsia (PE). As such, the potential for the administration of HCQ to prevent PE in other high-risk pregnancies is an important clinical research agenda among maternal and fetal medicine specialists. Mechanistically, the anti-inflammatory and immunomodulatory effects of HCQ can offer vascular protection and inhibit the placental dysfunction-associated thrombotic changes underlying the pathophysiology of PE, fetal growth restriction (FGR) and fetal death in utero (FDIU). Placenta-mediated complications exhibit a distinctive overlapping syndrome between pregnancies, and low-dose aspirin is the only prevention method currently in use. This study investigated the effects of improvements in outcomes with HCQ administration in high-risk pregnancies complicated by a previous experience of PE, FGR or FDIU.

METHODS AND ANALYSIS

This multicentre, open-label, single-arm trial commenced on 31 May 2022, in three tertiary hospitals in Korea. Pregnant women with a prior history of PE, FGR or FDIU are eligible to participate. This single-arm study set the previous study with the most similar inclusion criteria, aspirin dose and drug administration period as the comparison group. The required sample size was determined to be 58, with an expected dropout rate of 10%.

ETHICS AND DISSEMINATION

This study protocol was approved by the following institutions and committees: Institutional Review Boards of Chung-Ang University Gwangmyeong Hospital (2304-082-056), Samsung Medical Center (2021-11-087-003) and Kyungpook National University Chilgok Hospital (2021-06-005-006) and the Ministry of Food and Drug Safety. The results will be disseminated to the general public, grant funder, maternal-fetal medicine specialists and other researchers.

TRIAL REGISTRATION NUMBER

NCT05287321.

Intravenous immunoglobulin therapy: usage patterns and response to treatment in Qatar over ten years

Background

IVIg is a blood-derived antibody product initially designed as a replacement therapy in inborn errors of immunity (IEIs). However, over the last 50 years, IVIg has been used to treat a growing range of autoimmune, autoinflammatory, and secondary immunodeficiency disorders. The US FDA has licensed IVIg for use in the treatment of nine clinical indications; although, IVIg global usage extends to off-label indications with variable treatment responses. Data from Qatar on the use of IVIg is scarce; thus, hampering the formulation of local policies. This study aimed to examine the utilization patterns, clinical indications, and safety profile of IVIg usage in Qatar; a nation with a predominantly young population, and to investigate the response rates to short- and long-term IVIg treatment, as well as explore associations between age at first IVIg dose, clinical indication, and treatment response.

Methods

A retrospective chart review was conducted of patients who received IVIg between March 2009, and March 2019, in Hamad General Hospital, Qatar. Demographics, immediate adverse effects of IVIg, and treatment response were collected. IVIg clinical indications were categorized into FDA- and/or EMA-approved, those supported by international guidelines; those approved as second-line therapy, and those with low or no supportive evidence.

Results

IVIg was used for 63 indications during the 10-years. The age of patients skewed towards a younger demographic (median (IQR) 24 (44-6) years); however, no significant differences in response to short- and long-term treatment between age groups were observed. Of the 841 patients, 62% received IVIg in concordance with international recommendations, while 14% bestowed the treatment for indications with low or no supportive evidence. Immediate IVIg adverse effects were documented in 4% of patients in all of the infusions received, with headaches being the most prevalent (1.8%). Variable treatment responses were observed, with the highest recovery reported in immune thrombocytopenic purpura (35%), followed by transverse myelitis (28%).

Conclusion

This study provided crucial insights into IVIg utilization, safety, and treatment outcomes in Qatar's young population. Despite variability in treatment responses and off-label use, adherence to international recommendations remained eminent. Further research is warranted to inform local guidelines and optimize IVIg therapy outcomes.

Harnessing the potential of CAR-T cell in lupus treatment: From theory to practice

Systemic Lupus Erythematosus (SLE) is a rare, heterogeneous, potentially life-threatening autoimmune disease. Presence of kidney or other major organ (brain, heart or lung) involvement are predictors of poor outcome and in a subset of patients resistant to 1st or 2nd line conventional treatment. The 10-year mortality remains around 10-15 %. Chimeric Antigen Receptors (CAR) are molecules that allow to redirect the engineered immune cells towards specific target antigens and to simultaneously boost their activation. Following breakthrough results observed in the treatment of hematological malignancies, conventional CAR T-cell therapy has recently been applied to refractory SLE patients. Compared to the use of monoclonal antibodies, anti-CD19 CAR T-cells allow to achieve deeper depletion of autoreactive B cells, notably at site of inflamed tissues and lymphoid organs (i.e. lymph node), to suppress interferon signature and to restore the immune tolerance with the reemergence of naïve B-cells with a new repertoire. All clinical data reported in SLE patients so far showed that autologous anti-CD19 CAR T-cell treatment allowed impressive short- and longer-term resolution of lupus nephritis and other severe disease-related manifestations, without major toxicities and only mild cytokine-release syndrome. These clinical effects persisted after B-cell reconstitution and were associated with normalization of double-stranded DNA antibodies and complement levels in drug-free patients until three years after the procedure. Overall, these pioneering experiences show unique clinical and immunological response to CAR T-cell therapy in SLE, and the need for extended follow-up to determine its long-term efficacy.

Cutaneous Manifestations of Systemic Lupus Erythematosus and Their Correlation With Cardiac Involvement

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder characterized by widespread immune dysregulation that affects multiple organ systems, including the skin and cardiovascular system. The crosstalk between different cell death pathways-such as apoptosis, necroptosis, and neutrophil extracellular trap (NETosis), plays a pivotal role in the pathogenesis of SLE, influencing both cutaneous and cardiac manifestations. Cutaneous lupus erythematosus (CLE) is one of the most common early signs of SLE, affecting up to 80% of patients. CLE presents in several forms, including acute, subacute, and chronic lesions, each with varying degrees of association with systemic disease. Cardiac involvement, although often underrecognized, significantly contributes to morbidity and mortality in SLE patients, manifesting as pericarditis, myocarditis, valvular disease, and accelerated atherosclerosis. Emerging research suggests that these cutaneous and cardiac manifestations may be connected through shared immune mechanisms, including immune complex deposition, endothelial dysfunction, and chronic inflammation driven by cytokines such as Interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). The severity of skin involvement may correlate with an increased risk of cardiovascular events, underscoring the importance of early diagnosis and a multidisciplinary approach to treatment. This review explores the crosstalk among cell death pathways in SLE and examines how these pathways contribute to both cutaneous and cardiac manifestations. Furthermore, it highlights the clinical implications of this crosstalk and discusses potential therapeutic strategies aimed at modulating these cell death pathways to improve patient outcomes. Challenges and gaps in current research are also addressed, emphasizing the need for further investigation into these complex interactions.

Belimumab 10 years later: how drug positioning has changed

We analysed the change in the positioning of belimumab (BLM) in systemic lupus erythematosus (SLE) treatment in the first decade of real-life use, by providing data about patients treated by this biological drug in the Sapienza Lupus Cohort. We evaluated SLE patients treated by BLM according to the current clinical practice. Data of each patient were collected, focusing on previous and concomitant treatments. Finally, the drug retention rate was assessed. Since August 2013, 138 SLE patients started BLM (M/F 7/131; median age 49 years, IQR 13.25; median disease duration 214 months, IQR 180). To evaluate the change in BLM positioning, we divided patients according to the date of starting treatment as below: patients treated from 2013 to 2018 (period 1) and those treated since 2019 to date (period 2). Indeed, the median number of previous immunosuppressant drugs was significantly higher in patients treated in period 1 [3 (IQR 1.25) versus 1 (IQR 1.75), p = 0.0002]. Furthermore, 15.9% of patients treated in period 2 were not previously treated by immunosuppressant drugs, compared with 5.2% in period 1 (p = 0.01). Finally, the 24-month drug survival was significantly higher in patients previously treated with ≤ 1 immunosuppressant drug in comparison with those treated with ≥ 2 drugs (69.1% versus 43.4%, p = 0.0097, HR 0.49; 95% CI 0.27-0.88). Our data clearly described the progressive anticipation of BLM prescription in the first 10 years of clinical practice, underlining as choosing earlier biological agents could positively influence the drug retention rate.

Polygenic Landscape of Cryptogenic New-Onset Refractory Status Epilepticus: A Comprehensive Whole-Genome Sequencing Study

Cryptogenic new-onset refractory status epilepticus (cNORSE) is a devastating condition with unclear pathogenesis. Here, we analyzed the genetic underprints of 31 cNORSE patients from an autoimmune encephalitis observational cohort through whole-genome sequencing. Compared to their controls, cNORSE patients exhibited elevated polygenic risk scores (PRS) for traits associated with autoimmune diseases. The individual PRS against these diseases were correlated with specific clinical phenotypes of cNORSE. The variants were enriched in genes expressed in the central nervous system and lymphocytes. These results suggest a shared genetic framework between cNORSE and other autoimmune/autoinflammatory diseases, and its involvement in the disease pathogenesis. ANN NEUROL 2024;96:1201-1208.

Effect of Shared Decision-Making on Trust in Physicians in the Management of Systemic Lupus Erythematosus: The Trust Measurement for Physicians and Patients With Systemic Lupus Erythematosus Prospective Cohort Study

OBJECTIVE

Few studies have explored whether the involvement of patients in shared decision-making (SDM) is beneficial to the management of systemic lupus erythematosus (SLE). Therefore, this study investigated the relationship between patient participation in SDM and their trust in physicians using data from the Trust Measurement in Physicians and Patients With SLE (TRUMP2-SLE) study.

METHODS

Data regarding the nine-item Japanese version of the Shared Decision-Making Questionnaire (SDM-Q-9) scores, Trust in Physician Scale (TIPS) scores, and Abbreviated Wake Forest Physician Trust Scale (A-WFPTS) scores for interpersonal trust in a physician and trust in the medical profession were collected from patients with SLE who visited the outpatient clinics of five facilities in Japan through a self-administered questionnaire. The relationships among these scores were analyzed by general linear models with cluster-robust variance.

RESULTS

This study included 433 patients with SLE. The median baseline TIPS and A-WFPTS (attending physician version) scores were 82 (73-93) and 80 (70-95), respectively. A higher baseline SDM-Q-9 score was correlated with an increase in the TIPS score at one year (coefficient per 10-point [pt] increase, 0.94 pts, 95% confidence interval [CI] 0.16-1.72). A higher baseline SDM-Q-9 score was correlated with a higher A-WFPTS score for interpersonal trust (coefficient per 10-pt increase, 2.20 pts, 95% CI 1.44-2.96). The baseline SDM-Q-9 score was also correlated with an increase in the general physician version of the A-WFPTS score at one year (coefficient per 10-pt increase, 1.29 pts, 95% CI 0.41-2.18).

CONCLUSION

Engagement of patients with SLE in SDM elevates their trust in the attending physicians and health care providers, potentially enhancing doctor-patient relationships and overall health care trust.

Treatment of systemic lupus erythematosus: Analysis of treatment patterns in adult and paediatric patients across four European countries

OBJECTIVE

Multiple treatment options are recommended for Systemic Lupus Erythematosus (SLE) by clinical guidelines. This study aimed to explore SLE treatment patterns as there is limited real-world data of SLE medication utilisation, especially in childhood-onset SLE (cSLE).

METHODS

We conducted a longitudinal cohort study using five routinely collected healthcare databases from four European countries (United Kingdom, France, Germany, and Spain). We described the characteristics of adult and paediatric patients at time of SLE diagnosis. We calculated the percentage of patients commencing SLE treatments in the first month and year after diagnosis, reported number of prescriptions, starting dose, cumulative dose, and duration of each treatment, and characterised the line of therapy.

RESULTS

We characterised 11,255 patients with a first diagnosis of SLE and included 5718 in our medication utilisation analyses. The majority of adult SLE patients were female (range 80-88 %), with median age of 49 to 54 years at diagnosis. In the paediatric cohort (n = 378), 66-83 % of SLE patients were female, with median age of 12 to 16 years at diagnosis. Hydroxychloroquine and glucocorticoids were common first-line treatments in both adults and children, with second-line treatments including mycophenolate mofetil and methotrexate. Few cases of monoclonal antibody use were seen in either cohort. Initial glucocorticoid dosing in paediatric patients was often higher than in adults.

CONCLUSION

Treatment choices for adult SLE patients across four European countries were in line with recent therapeutic consensus guidelines. High glucocorticoid prescriptions in paediatric patients suggests the need for steroid-sparing treatment alternatives and paediatric specific guidelines.

Pilot Trial of Hydroxychloroquine as Add-On Therapy in Patients With Membranous Nephropathy

Introduction

Kidney Disease Improving Global Outcomes guidelines indicate that glucocorticoids and immunosuppressants comprise the first therapeutic regimens after 4 to 6 months of treatment for high-risk primary membranous nephropathy (PMN). However, some patients cannot achieve complete or partial remission at 6 months. This study aimed to evaluate the efficacy of traditional immunotherapy combined with hydroxychloroquine (HCQ), a well-known immune regulator, in patients with PMN.

Methods

This was a single-center, open-label, prospective study. We recruited 72 patients with nephrotic syndrome and PMN proven by renal biopsy from May 2020 to June 2024. We compared changes in proteinuria, serum albumin levels, estimated glomerular filtration rate (eGFR), and relapse rate at 3, 6, 9, and 12 months follow-up in 41 patients who received glucocorticoid and immunosuppressant, and in 31 who received HCQ plus standard-of-care.

Results

Baseline characteristics showed no statistical significance between the 2 groups. However, the HCQ group showed significantly reduced proteinuria compared to standard-of-care group. A reduced proteinuria was seen at 6 months (1.2 [0.4-2.2] vs. 2.2 [1.0-3.8] g/d, P = 0.029) and the relapse rate with 12 months follow-up was also significantly decreased in the HCQ group compared to the standard-of-care group (3.7% vs. 23.3%, P = 0.033).

Conclusions

HCQ may serve as an effective add-on therapy for PMN.

Belimumab safety in adult and paediatric Chinese patients with systemic lupus erythematosus: A Phase 4, multicentre, observational study

OBJECTIVE

Although belimumab has been widely used in patients with systemic lupus erythematosus (SLE) globally, real-world safety data among Chinese patients are limited, particularly for children. This study assessed the safety and tolerability of belimumab in adult and paediatric patients with SLE in China in real-world clinical practice.

METHODS

This Phase 4, multicentre, prospective, observational study enrolled patients prescribed intravenous belimumab by their physicians in tertiary hospitals, independent of a clinical study, during routine clinical visits between May 2021 and May 2022. Patients could have been receiving belimumab prior to enrolment. The primary objective was to describe the incidence of adverse events (AEs), serious AEs (SAEs), adverse drug reactions (ADRs) and AEs of special interest (AESIs) over the 24-week follow-up period. Data were collected at enrolment and approximately 4, 12 and 24 weeks post-enrolment, during routine clinical visits. AEs, ADRs and SAEs were collected as independent events. The safety population comprised patients who received ≥1 dose of belimumab and completed ≥1 follow-up visit.

RESULTS

Overall, 417 patients were included in the analysis (safety population); 89.2% were female and mean (standard deviation) age was 35.5 (11.9) years. AEs were reported in 158 patients (37.9%) and were mostly mild (79.1%). The most common AEs were upper respiratory tract infections (n = 19, 4.6%) and hypokalaemia (n = 18, 4.3%; all mild). Among 22 patients (5.3%) with SAEs, four patients (1.0%) had drug-related SAEs (pneumonia, respiratory tract infection, gingivitis and decreased white blood cell and neutrophil count). ADRs were experienced by 25 patients (6.0%), most commonly urinary tract infections (n = 5, 1.2%). There were no fatal SAEs. AESIs occurred in 14 patients (3.4%), including infections of interest (n = 5, 1.2% all herpes zoster), serious selected psychiatric events (n = 3, 0.7%) and infusion-related systemic and anaphylactic reactions (n = 7, 1.7%). Of 14 paediatric patients enrolled, six experienced AEs, zero ADRs, two SAEs and one AESI.

CONCLUSION

Belimumab was generally well tolerated in adult and paediatric patients with SLE in this real-world setting in China, with no new safety signals identified. Future assessment of long-term belimumab safety in China beyond 24 weeks will extend this current body of evidence.

Clinical features, imaging findings, and outcomes of acute abdominal pain in systemic lupus erythematosus: comparing mesenteric vasculitis, non-mesenteric vasculitis, and surgical conditions

OBJECTIVES

To determine the spectrum, clinical features and outcomes in systemic lupus erythematosus (SLE) patients with acute abdominal pain (AAP).

METHOD

Medical records of SLE patients in a lupus cohort from January 1987 to June 2023 were reviewed. Patients with AAP requiring hospitalization were identified and categorized into 3 groups: lupus mesenteric vasculitis (LMV), non-LMV, and surgical AAP. Each AAP episode represented one patient.

RESULTS

Of 1,538 patients in the cohort, 62 (4.03%) had 93 episodes of AAP. After exclusion, 31 patients had 39 LMV episodes, and 30 had 40 non-LMV episodes (19 due to surgical AAP). Seventy-six of the 79 AAP episodes (96.20%) were in females, with a mean ± SD age and median (IQR) disease duration of 36.76 ± 13.60 years and 6 (2, 9) years, respectively. Patients in the LMV group had more fever, nausea and vomiting, and diarrhea than those in the non-LMV group. They also had more small bowel involvement, bowel wall thickening, target water enhancement signs, mesenteric vessels engorgement and mesenteric fat cloudiness, and higher SLE disease activity. These differences were more pronounced when compared to the surgical AAP group. Treatment with corticosteroids and immunosuppressive drugs gave favorable outcomes in the LMV group. Two of 40 (5.00%) non-LMV AAP patients died, of which 1 (5.26%) was in the surgical AAP group.

CONCLUSION

LMV was common among SLE patients admitted for AAP. LMV usually presented with fever, gastrointestinal dysmotility symptoms, diffused abdominal pain, together with evidence of active disease. Localized abdominal pain with peritoneal signs favored surgical AAP. Key Points • Lupus mesenteric vasculitis is common among SLE patients presenting with acute abdominal pain. Its presence often associates with gastrointestinal symptoms together with other clinical manifestations of SLE • The signs in abdominal computed tomography findings are not specific and could be observed in other causes of abdominal pain in SLE. Interpretation of these signs should be cautionary and accompanied by history taking and physical abdominal findings • Treatment of lupus mesenteric vasculitis with corticosteroids alone, or in combination with immunosuppressive drugs, usually results in good outcomes.

Exploring the contribution of genetics on the clinical manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a complex autoimmune disease characterized by diverse clinical manifestations affecting multiple organs and systems. The understanding of genetic factors underlying the various manifestations of SLE has evolved considerably in recent years. This review provides an overview of the genetic implications in some of the most prevalent manifestations of SLE, including renal involvement, neuropsychiatric, cutaneous, constitutional, musculoskeletal, and cardiovascular manifestations. We discuss the current state of knowledge regarding the genetic basis of these manifestations, highlighting key genetic variants and pathways implicated in their pathogenesis. Additionally, we explore the clinical implications of genetic findings, including their potential role in risk stratification, prognosis, and personalized treatment approaches for patients with SLE. Through a comprehensive examination of the genetic landscape of SLE manifestations, this review aims to provide insights into the underlying mechanisms driving disease heterogeneity and inform future research directions in this field.

Renal response status to predict long-term renal survival in patients with lupus nephritis: results from the Toronto Lupus Cohort

OBJECTIVE

To evaluate modified versions of the Belimumab International Study in Lupus Nephritis (BLISS-LN) belimumab study primary efficacy renal response (mPERR) and complete renal response (mCRR) criteria (excluding mandatory corticosteroid tapering) as predictors of real-world, long-term renal outcomes among patients with lupus nephritis (LN).

METHODS

This retrospective, observational study (GSK Study 212866) used deidentified data between 1970 and 2015 from the University of Toronto Lupus Cohort from adults diagnosed with systemic lupus erythematosus and biopsy-proven Class III±V, IV±V or V LN. At 24 months postbiopsy, patients were retrospectively indexed as responders/non-responders based on mPERR (estimated glomerular filtration rate (eGFR) ≤20% below biopsy value/≥60 mL/min/1.73 m2 and urine protein:creatinine ratio (uPCR) ≤0.7 g/day) or mCRR (eGFR ≤10% below biopsy value/≥90 mL/min/1.73 m2 and uPCR ≤0.5 g/day) criteria. The association between index mPERR (primary outcome) or mCRR (secondary outcome) status and long-term (up to 25 years, until censoring or death) renal survival (no progression to end-stage kidney disease (eGFR <30 mL/min/1.73 m2, dialysis or transplant) or death) was assessed.

RESULTS

Overall, 179 patients were included in the analysis (mPERR responders, n=128; non-mPERR responders, n=51). Most patients were female (87.2%); the mean (SD) age was 34.1 (11.3) years.Long-term renal survival was attained for 78.9% of mPERR responders and 60.8% of non-mPERR responders; achieving mPERR was associated with an increased likelihood of long-term renal survival versus not achieving mPERR (log-rank p=0.0119). Overall, 102 patients were mCRR responders, and 77 were non-mCRR responders. Long-term renal survival was attained for 80.4% of mCRR responders and 64.9% of non-mCRR responders; achieving mCRR was associated with an increased likelihood of long-term renal survival than not achieving mCRR (log-rank p=0.0259).

CONCLUSIONS

Achieving mPERR or mCRR was associated with improved long-term renal survival, highlighting that these statuses are suitable predictors of long-term renal outcomes in patients with LN.

Coexistent pleural effusion is found to be associated with aggravated subclinical myocardial injury in systemic lupus erythematous using cardiovascular magnetic resonance imaging

Objective

Pleural effusion (PE) is a common pulmonary manifestation in patients with systemic lupus erythematosus (SLE), and is associated with disease activity. However, little is known regarding the additive effects of PE on cardiac function. Therefore, this study aimed to investigate multi-parameter cardiovascular magnetic resonance imaging (CMR) findings in SLE patients with PE and to explore whether cardiac involvement is associated with PE.

Methods

Patients with SLE and age-matched/sex-matched healthy controls were included in this study. Patients with SLE were diagnosed according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria. Moreover, the PE diagnosis was based on computed tomography, and the height of the effusion was > 5 mm. All enrolled individuals underwent CMR imaging, including cine and late gadolinium enhancement (LGE), T1, and T2 mapping imaging. The left and right ventricular function, LGE, T1, extracellular volume (ECV), and T2 values were evaluated.

Results

A total of 111 patients with SLE were enrolled, of whom 26 (23.42%) had PE. White cell count, hemoglobin, CRP, ESR, and lactate dehydrogenase levels were higher in SLE patients with PE than in SLE patients without PE (P<0.05). LGE was more prevalent in SLE patients with PE compared with those without PE (P<0.001). In addition, Native T1 (1348 ± 65 ms vs. 1284 ± 67 ms vs. 1261 ± 41 ms; P<0.001), ECV (31.92 ± 4.16% vs. 28.61 ± 3.60% vs. 26.54 ± 2.94%; P<0.001), and T2 (44.76 ± 3.68 ms vs. 41.96 ± 3.62 ms vs. 39.21 ± 2.85 ms; P<0.001) values were high in SLE patients with PE, intermediate in SLE patients without PE, and the lowest in the control group. Linear regression analysis demonstrated that PE was independently associated with LGE (β=0.329; P<0.05), T1 (β=0.346; P<0.05), ECV (β=0.353; P<0.05), and T2 (β=0.201; P<0.05).

Conclusions

SLE patients with PE have a higher prevalence of LGE and more diffuse myocardial fibrosis and edema than SLE patients without PE. Moreover, PE is associated with increased diffuse interstitial fibrosis and edema.

Examining the safety of belimumab, especially in children: an analysis of real-world pharmacovigilance data from the US FDA adverse event reporting system (FAERS) database

BACKGROUND

Belimumab was approved in the US in 2019 for children with Systemic lupus erythematosus (SLE), making it the only medicine that can treat SLE in both adults and children. The authors retrospectively investigated adverse events (AEs) by data-mining a self-reported database.

RESEARCH DESIGN AND METHODS

PRR, ROR, and BCPNN were used to assess the association between belimumab and AEs. The definition relied on system organ class (SOC) and peferred terms (PT) by the Medical Dictionary for Regulatory Activities (MedDRA).

RESULTS

A total of 15,316,605 AE reports were retrieved from the FAERS database, and 19,832 AE reports were identified after the data cleaning process. Based on the disproportionality analysis at the PT level, depressive (N = 420), ill-defined disorder (N = 304), injection site hemorrhage (N = 297), lupus nephritis (N = 198), live birth (N = 96) and proteinuria (N = 77) had relatively higher frequencies than other AEs, suggesting that these AEs are more likely to occur in the real world for patients taking belimumab.

CONCLUSIONS

This study explores valuable potential AEs of belimumab at the SOC and PT levels, respectively. To provide a reference for decision-making on belimumab, including its use in children, and to promote rational clinical dosing.

IL-10 mediates pleural remodeling in systemic lupus erythematosus

BACKGROUND

Interleukin-10 (IL-10), a pivotal anti-inflammatory cytokine, has gotten attention for its involvement in tissue remodeling and organ fibrosis. Pleurisy and subsequent pleural remodeling are recognized as quantifiable indicators of systemic lupus erythematosus (SLE) activity. However, the role of IL-10 in SLE-associated pleural remodeling remains unknown. In this study, we investigated role of IL-10 in SLE-associated pleural remodeling and the underlying mechanism.

METHODS

Clinical data and serum specimens were obtained from SLE patients, while pleural mesothelial cells and mouse models served as primary experimental subjects. The protein expression-related technologies, histopathological staining, and other experimental methods were used in the study.

RESULTS

Our investigation got several key findings. Firstly, serum obtained from SLE patients with pleural thickening was found to induce pleural mesothelial cell remodeling. Subsequently, heightened levels of IL-10 were found in serum from SLE patients with pleural thickening compared to that of SLE patients without pleural thickening. Secondly, administration of recombinant IL-10 was confirmed its ability to induce pleural mesothelial cell remodeling, on the contrary, this remodeling was effectively mitigated by IL-10 inhibition. Notably, blockade of IL-10 significantly prevented collagen deposition and prevented thickening in pleura of SLE mouse models. Lastly, the IL-10/JAK2/STAT3/HIF1α/TMEM45A/P4HA1 signaling axis was elucidated to mediate pleural remodeling and thickening.

CONCLUSIONS

Our study uncovered that IL-10 mediated pleural remodeling in SLE. We suggested that serum IL-10 level exceeding 6.32 pg/mL was a potential reference threshold for predicting pleural thickening in SLE patients.

Advanced Parameters of Myocardial Strain and Cardiac Biomarkers Indicate Subclinical Systolic Myocardial Dysfunction in Patients with Systemic Lupus Erythematous

Background: Systemic lupus erythematosus (SLE) is characterized by inflammation and cardiovascular complications. Our study aimed to investigate subclinical and early indicators of systolic myocardial dysfunction in SLE patients using advanced echocardiographic methods and biomarkers. Methods: In this cross-sectional study, we enrolled 102 SLE patients without known cardiac impairment and 51 healthy controls. Demographics, disease characteristics, laboratory results, disease activity (SLEDAI), and organ damage (SDI) indices were recorded. Left ventricular global longitudinal strain (GLS) and myocardial work indices were assessed by utilizing speckle tracking echocardiography. In addition, high-sensitivity C-reactive protein (hsCRP), high-sensitivity troponin (hsTn), and N-terminal-pro B-type natriuretic peptide (NT-proBNP) levels were measured in blood samples. Results: In comparison with controls, SLE patients had significantly higher GLS (-19.94 ± 2.71% vs. -21.15 ± 1.55%, p < 0.001) and global wasted work (GWW) (94 ± 71 mmHg% vs. 71 ± 49 mmHg%, p = 0.025). Notably, NT-proBNP and hsTn were threefold and twofold higher in the SLE group compared with the control group, respectively (p < 0.001). Within the SLE cohort, in patients with at least moderate disease activity (SLEDAI ≥ 4), both biomarkers were significantly more elevated than those with low disease activity (SLEDAI < 4). Notably, hsTn levels remained within the normal range. Conclusions: Advanced echocardiographic parameters combined with specific biomarkers have a promising role in detecting systolic dysfunction in SLE patients, potentially enabling timely interventions to mitigate cardiovascular risk.

Fibromyalgia, mood disorders and chronic damage are the main determinants of worse quality of life in systemic lupus erythematosus patients: Results from a cross-sectional analysis

OBJECTIVE

As suggested by the EULAR recommendations, a comprehensive management of Systemic Lupus Erythematosus (SLE) should include the evaluation of disease activity, chronic damage, and quality of life (QoL). QoL is significantly impaired in SLE patients, even in those achieving a state of remission, suggesting the possible contribution of other factors. Thus, in the present study we aimed at analyzing QoL in a large SLE cohort by using LupusQoL, and at identifying the main determinant of poorer QoL.

METHODS

We conducted a cross-sectional study by including consecutive SLE patients diagnosed according to the 2019 ACR/EULAR criteria. Clinical, laboratory and therapeutical data were collected. Disease activity was assessed by SLEDAI-2k, while chronic damage by the SLICC Damage Index (SDI). The diagnosis of fibromyalgia was made in accordance with the ACR criteria (2016). At the time of the enrollment, all patients completed the following questionnaires: LupusQoL to assess quality of life and hospital anxiety and depression scale (HADS) for anxiety and depression.

RESULTS

Our analysis included 237 SLE patients [92.4% female, median age 46 years (IQR 19.5), median disease duration 156.8 months (IQR 180.6)]. At the time of enrollment, we found a mean SLEDAI-2k of 1.7 (DS 2.4); 104 patients (43.9%) had chronic damage, with a mean SDI value of 0.8 (DS 1.3). Patients diagnosed with fibromyalgia were 69 (29.1%); moreover, HADS questionnaire identified a condition of anxiety and depression in 112 (47.3%) and 94 (39.7%) patients, respectively. The most compromised domain in the LupusQoL resulted "fatigue", followed by "burden to others". Patients with SDI ≥ 1 showed lower quality of life than patients without chronic damage, as demonstrated by significantly lower values in all items of the LupusQoL (p < .01). Furthermore, significantly lower values in all the LupusQoL domains were observed in patients with fibromyalgia, anxiety and depression, in comparison to those patients without these manifestations (p < .0001). No association was demonstrated between QoL and disease activity. Finally, the linear regression analysis confirmed mood disorders, in particular depression, and fibromyalgia as the main determinants of worse quality of life in our cohort.

CONCLUSIONS

The present study demonstrated the influence of different factors in the quality of life of SLE patients. In particular, the presence of mood disorders, fibromyalgia and chronic damage resulted the main determinants of poorer QoL. This evidence reinforces the need for a comprehensive patient care.

Comparison of quantitative and qualitative anti-dsDNA assays

OBJECTIVE

In evaluation of systemic lupus erythematosus (SLE), anti-double-stranded DNA antibodies (anti-dsDNA) play a significant role in diagnosis, monitoring SLE activity, and assessing prognosis. However, evaluations of the performance and limitations for recently developed methods for anti-dsDNA assessment are sparse.

METHODS

Specimens used for antinuclear antibody testing (n = 129) were evaluated for anti-dsDNA assay comparability across 4 medical centers in the United States. The methods compared were Werfen Quanta Lite dsDNA, Zeus Scientific dsDNA Enzyme Immunoassay, Bio-Rad multiplex immunoassay (MIA) dsDNA, ImmunoConcepts Crithidia, and Bio-Rad Laboratories Crithidia.

RESULTS

For quantitative anti-dsDNA measurements, Spearman's correlation coefficient was highest between Zeus and Werfen (ρ = 0.86; CI, 0.81-0.90; P < .0001). Comparison of MIA to Werfen or Zeus yielded similar results to each other (ρ = 0.58; CI, 0.44-0.68; P < .0001; and ρ = 0.59; CI, 0.46-0.69; P < .0001, respectively), but lower than the correlation between Zeus and Werfen. Positive concordance between assays ranged from 31.4% to 97.1%, and negative concordance between assays ranged from 58.5% to 100%. The detection of anti-dsDNA in those with SLE diagnosis ranged from 50.9% to 77.4% for quantitative assays and 15.1% to 24.5% for Crithidia assays.

CONCLUSION

Current quantitative anti-dsDNA assays are not interchangeable for patient follow-up. Crithidia-based assays demonstrate high negative concordance and lack positive concordance among the methods.

The safety and efficacy of Baricitinib for systemic lupus erythematosus: a systematic review and meta-analysis of randomized controlled trials

Background and objective

Baricitinib is a JAK1 and JAK2 inhibitor approved for treating active rheumatoid arthritis and atopic dermatitis. Therefore, the authors aim to evaluate the safety and efficacy of once-daily oral Baricitinib 2 mg or 4 mg versus placebo in active SLE patients receiving standard care.

Methods

The authors synthesized randomized controlled studies (RCTs) from MEDLINE, Scopus, EMBASE, PubMed, and Cochrane Library until 20 March 2023. The study protocol was registered in PROSPERO.

Results

Three RCTs with 1849 participants were included. The Baricitinib group had a significant SRI-4 response [RR: 1.11 with 95% CI (1.03, 1.21), P=0.008] and greater than or equal to 4-point SLEDAI-2K domain improvement [RR: 1.13 with 95% CI (1.02, 1.25), P=0.02] compared to the placebo group; however, there was no statistically significant difference between the two groups, regarding the secondary endpoints. For safety outcomes, Baricitinib was significantly associated with a higher incidence of Any serious adverse event [RR: 1.48 with 95% CI (1.07, 2.05), P=0.02].

Conclusion

Baricitinib is associated with significant outcomes of SRI-4 response, greater than or equal to 4-point improvement SLEDAI-2K score, and Joint Indices. Regarding safety, there was no difference in the outcomes other than the serious adverse events.

Pseudo-Pseudo Meigs' Syndrome in a 40-Year-Old Woman Without a Prior Systemic Lupus Erythematosus Diagnosis

Pseudo-pseudo Meigs' syndrome (PPMS), also known as Tjalma syndrome, is an exceptionally rare condition marked by pleural effusion, ascites, and elevated CA-125 levels, usually in the context of systemic lupus erythematosus (SLE) without any associated ovarian tumors. We report the case of a 40-year-old woman who presented with a four-month history of fatigue, nausea, weight loss, abdominal pain, and pleural effusion. Initial diagnostic workup revealed ascites, elevated CA-125 levels, and pleural effusions, with no evidence of malignancy. Notably, the patient had no prior history of SLE. Comprehensive clinical, biological, and immunological evaluation eventually confirmed SLE, leading to a diagnosis of PPMS. The patient was treated with methylprednisolone and Plaquenil, with careful monitoring for potential complications. This case highlights the diagnostic challenges posed by PPMS, particularly in the absence of a prior SLE diagnosis. The unusual initial presentation underscores the importance of considering PPMS in differential diagnoses to avoid misdiagnosis and unnecessary invasive procedures. Early recognition and appropriate management are essential for optimizing patient outcomes in this rare and complex syndrome.

Approach to Glomerular Disease in Pregnancy

The presence of glomerular diseases in pregnancy presents challenges to both patients and nephrologists. The preconception planning in patients with kidney disease involves comprehensive stratification, treatment optimization, and comorbidity assessment, requiring nephrologists to engage in well-informed decision-making processes alongside their patients. There is a necessity for a multidisciplinary approach to meet their complex healthcare needs. Effective control of blood pressure, proteinuria, and disease activity are pivotal in mitigating adverse pregnancy events. This comprehensive review intends to equip nephrologists with the requisite knowledge and understanding to navigate the intricate landscape of glomerular diseases in pregnancy. It delves into the challenges associated with the diagnosis of glomerular diseases, the significance of preconception counseling, and the nuances of antenatal and postnatal care. Additionally, the article provides insights into the management and prognosis of glomerular diseases, shedding light on the judicious use of immunosuppression as a therapeutic tool.

Attainment of remission and low disease activity after treatment with belimumab in patients with systemic lupus erythematosus: a post-hoc analysis of pooled data from five randomised clinical trials

BACKGROUND

Disease remission or low disease activity are key treatment targets for patients with systemic lupus erythematosus (SLE). Pivotal trials of belimumab were conducted before the introduction of these targets. In this study, we aimed to pool data across trials to assess attainment of remission and low disease activity in a large, racially and culturally diverse patient population with SLE.

METHODS

In this integrated post-hoc analysis, we pooled data from five phase 3 trials of belimumab (BLISS-76 [NCT00410384], BLISS-52 [NCT00424476], BLISS-NEA [NCT01345253], BLISS-SC [NCT01484496], and EMBRACE [NCT01632241]), in patients with active, autoantibody-positive SLE. Patients were randomly assigned to receive belimumab (10 mg/kg per month intravenously or 200 mg per week subcutaneously) or placebo, plus standard therapy. The proportion of patients with Definitions of Remission in SLE (DORIS) remission and lupus low disease activity state (LLDAS) were analysed every 4 weeks from week 4 to week 52 for belimumab versus placebo, using modified Poisson regression adjusted for trial variance, in all patients and in subgroups per baseline SLE Disease Activity Index-2000 score (<10 or ≥10); anti-double stranded DNA positivity (yes or no); low complement 3 (C3) or C4 levels (yes or no); anti-dsDNA positivity or low C3 or C4 levels (yes and no); prednisone-equivalent dose (≤7·5 mg per day or >7·5 mg per day); antimalarial use (yes or no); and by race (Black African ancestry or African American, Asian, Indigenous American, or White).

FINDINGS

Data for 3086 patients (1869 in the belimumab group and 1217 in the placebo group) were analysed. 2913 (94%) of 3086 patients were women and 173 (6%) were men, and the median age was 36 years (IQR 28-45). The proportion of patients with DORIS remission was significantly higher in the belimumab group than the placebo group at weeks 28, 48, and 52 (week 52: 148 [8%] of 1869 participants vs 68 [6%] of 1217 participants; risk ratio 1·51 [95% CI 1·15-1·99]; p=0·0055). The proportion of patients who attained LLDAS was higher in the belimumab group than the placebo group at weeks 8, 24, 32-52 (week 52: 322 [17%] of 1869 participants vs 125 [10%] of 1217 participants; 1·74 [1·44-2·12]; p<0·0001). A higher proportion of patients had DORIS remission at week 52 in the belimumab group than the placebo group among all baseline subgroups denoting high disease activity, with the exception of those on a prednisone-equivalent dose higher than 7·5 mg per day in whom there was no difference for DORIS remission with belimumab versus placebo. The proportion of patients with LLDAS was significantly higher among patients in the belimuab group than those who received placebo from week 44 in all baseline subgroups denoting high disease activity or earlier in some subgroups, and the differences were maintained at week 52.

INTERPRETATION

In adults with active SLE, belimumab plus standard therapy yielded greater benefit than placebo plus standard therapy in attaining DORIS remission (for which low rates were attained in both groups) and LLDAS, with differences observed as early as week 28 for DORIS remission and week 8 for LLDAS.

FUNDING

Swedish Rheumatism Association, King Gustaf V's 80-year Foundation, Swedish Society of Medicine, Nyckelfonden, Professor Nanna Svartz Foundation, Ulla and Roland Gustafsson Foundation, Region Stockholm, and the Karolinska Institutet.