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Smith EMD, Aggarwal A, Ainsworth J, Al-Abadi E, Avcin T, Bortey L, Burnham J, Ciurtin C, Hedrich CM, Kamphuis S, Lambert L, Levy DM, Lewandowski L, Maxwell N, Morand E, Özen S, Pain CE, Ravelli A, Saad Magalhaes C, Pilkington C, Schonenberg-Meinema D, Scott C, Tullus K, Beresford MW. Defining remission in childhood-onset lupus: PReS-endorsed consensus definitions by an international task force. Clin Immunol 2024; 263:110214. [PMID: 38604255 DOI: 10.1016/j.clim.2024.110214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/30/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To derive childhood-onset SLE (cSLE) specific remission definitions for future treat-to-target (T2T) trials, observational studies, and clinical practice. METHODS The cSLE International T2T Task Force conducted Delphi surveys exploring paediatric perspectives on adult-onset SLE remission targets. A modified nominal group technique was used to discuss, refine, and agree on the cSLE remission target criteria. RESULTS The Task Force proposed two definitions of remission: 'cSLE clinical remission on steroids (cCR)' and 'cSLE clinical remission off steroids (cCR-0)'. The common criteria are: (1) Clinical-SLEDAI-2 K = 0; (2) PGA score < 0.5 (0-3 scale); (4) stable antimalarials, immunosuppressive, and biologic therapy (changes due to side-effects, adherence, weight, or when building up to target dose allowed). Criterion (3) in cCR is the prednisolone dose ≤0.1 mg/kg/day (maximum 5 mg/day), whereas in cCR-0 it is zero. CONCLUSIONS cSLE definitions of remission have been proposed, maintaining sufficient alignment with the adult-SLE definition to facilitate life-course research.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - J Ainsworth
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- Department of Paediatric Rheumatology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Slovenia
| | - L Bortey
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Burnham
- Department of Pediatric Rheumatology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - C Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Division of Medicine, University College London, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - S Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Lambert
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - D M Levy
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - L Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - N Maxwell
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, Australia
| | - S Özen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - C E Pain
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - A Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - C Saad Magalhaes
- Paediatric Rheumatology Division, Botucatu Medical School, Sao Paulo State, University (UNESP), Sao Paulo, Brazil
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - D Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious diseases, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - C Scott
- Department of Pediatric Rheumatology, University of Cape Town, Cape Town, South Africa
| | - K Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Selvaratnam R, Srivastava P, Tacker DH, Thebo J, Wheeler SE. Comparison of quantitative and qualitative anti-dsDNA assays. Lab Med 2024:lmae035. [PMID: 38801239 DOI: 10.1093/labmed/lmae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
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.
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Affiliation(s)
- Rajeevan Selvaratnam
- Laboratory Services, BayCare Health System, Tampa, FL, US
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Pooja Srivastava
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, US
| | - Danyel H Tacker
- Department of Pathology, Anatomy, and Laboratory Medicine, School of Medicine, West Virginia University, Morgantown, WV, US
| | | | - Sarah E Wheeler
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, US
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, US
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Barber MRW, Ugarte-Gil MF, Hanly JG, Urowitz MB, St-Pierre Y, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey-Goldman R, Manzi S, Jönsen A, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Pons-Estel BA, Cardwell FS, Alarcón GS, Clarke AE. Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2024:ard-2024-225613. [PMID: 38754981 DOI: 10.1136/ard-2024-225613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES This study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort. METHODS Patients from 31 centres in 10 countries were enrolled within 15 months of diagnosis and assessed annually. Five mutually exclusive disease activity states (DAS) were defined as (1) remission off-treatment: clinical (c) SLEDAI-2K=0, without prednisone/immunosuppressants; (2) remission on-treatment: cSLEDAI-2K=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; (3) LDA-Toronto Cohort (TC): cSLEDAI-2K≤2, without prednisone/immunosuppressants; (4) modified lupus LDA state (mLLDAS): SLEDAI-2K≤4, no activity in major organs/systems, no new activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants and (5) active: all remaining assessments.At each assessment, patients were stratified into the most stringent DAS fulfilled and the proportion of time in a DAS since cohort entry was determined. Annual DCs/ICs (2021 Canadian dollars) were based on healthcare use and lost workforce/non-workforce productivity over the preceding year.The association between the proportion of time in a DAS and annual DC/IC was examined through multivariable random-effects linear regressions. RESULTS 1692 patients were followed a mean of 9.7 years; 49.0% of assessments were active. Remission/LDA (per 25% increase in time in a remission/LDA state vs active) were associated with lower annual DC/IC: remission off-treatment (DC -$C1372; IC -$C2507), remission on-treatment (DC -$C973; IC -$C2604,) LDA-TC (DC -$C1158) and mLLDAS (DC -$C1040). There were no cost differences between remission/LDA states. CONCLUSIONS Our data suggest that systemic lupus erythematosus patients who achieve remission, both off and on-therapy, and reductions in disease activity incur lower costs than those experiencing persistent disease activity.
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Affiliation(s)
- Megan R W Barber
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Manuel Francisco Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray B Urowitz
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Diseases, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Yvan St-Pierre
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Caroline Gordon
- Rheumatology Research Group, Birmingham University Medical School, Birmingham, UK
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea (the Republic of)
- Hanyang Institute of Bioscience and Biotechnology, Seoul, Korea (the Republic of)
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Jorge Sanchez-Guerrero
- University Health Network, Toronto, Ontario, Canada
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sasha Bernatsky
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
| | - Joan T Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Paul R Fortin
- Centre ARThrite, CHU de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Dafna D Gladman
- Krembil Research Institute, Toronto, Ontario, Canada
- Lupus Program, Centre for Prognosis in The Rheumatic Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- The Kellgren Centre for Rheumatology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Michelle Petri
- Division of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Mary Anne Dooley
- Thurston Arthritis Research Centre, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Susan Manzi
- Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Cynthia Aranow
- The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | - S Sam Lim
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul University, Istanbul Medical Faculty, Capa, Istanbul, Turkey
| | | | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anca Askanase
- Division of Rheumatology, Columbia University Lupus Center, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autonmunes y Reumáticas, Rosario, Argentina
| | - Francesca S Cardwell
- Geography & Environmental Management, University of Waterloo, Waterloo, Ontario, Canada
| | - Graciela S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Ann E Clarke
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Mysler E, Monticielo OA, Al-Homood IA, Lau CS, Hussein H, Chen YH. Opportunities and challenges of lupus care in Latin America, the Middle East, and Asia-Pacific: A call to action. Mod Rheumatol 2024:roae001. [PMID: 38531074 DOI: 10.1093/mr/roae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/27/2023] [Indexed: 03/28/2024]
Abstract
Lupus remains a disease with a low prioritisation in the national agendas of many countries in Latin America, the Middle East, and Asia-Pacific, where there is a dearth of rheumatologists and limited access to new or even standard lupus treatments. There is thus an important need for education, advocacy, and outreach to prioritise lupus in these regions to ensure that patients receive the care they need. This article reviews some of the specific challenges facing the care and management of people with lupus in these regions and suggests strategies for improving patient outcomes. Specifically, we review and discuss (with a focus on the aforementioned regions) the epidemiology of lupus; economic costs, disease burden, and effects on quality of life; barriers to care related to disease assessment; barriers to effective treatment, including limitations of standard treatments, high glucocorticoid use, inadequate access to new treatments, and low adherence to medications; and strategies to improve lupus management and patient outcomes. We hope that this represents a call to action to come together and act now for the lupus community, policymakers, health authorities, and healthcare professionals to improve lupus management and patient outcomes in Latin America, the Middle East, and Asia-Pacific.
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Affiliation(s)
- Eduardo Mysler
- Organización Medica de Investigación, Buenos Aires, Argentina
| | - Odirlei Andre Monticielo
- Rheumatology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Chak Sing Lau
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China
| | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
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Altabás-González I, Rúa-Figueroa Í, Rubiño F, Mouriño C, Hernández-Rodriguez Í, Menor-Almagro R, Uriarte-Isacelaya E, Tomero E, Salman-Monte TC, Carrión-Barberá I, Galindo-Izquierdo M, Rodriguez-Almaraz ME, Inês LS, Jiménez N, Pego-Reigosa JM. Does remission in systemic lupus erythematosus according to the 2021 DORIS definition match the treating rheumatologist's judgement? Rheumatology (Oxford) 2024; 63:72-78. [PMID: 37039851 PMCID: PMC10765144 DOI: 10.1093/rheumatology/kead159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVES To assess agreement between the 2021 Definition Of Remission In SLE (DORIS) and physician-judged lupus activity. METHODS A cross-sectional analysis was conducted of data from a Spanish prospective multicentre study of SLE patients. We applied the 2021 DORIS criteria and assessed whether remission status based on this definition agreed with remission as per physician clinical judgement and reasons for disagreement between them. RESULTS Out of 508 patients [92% women; mean age (s.d.): 50.4 years (13.7)] studied, 267 (54.4%) met the criteria for 2021 DORIS remission. Based on physicians' judgement, 277 (55.9%) patients were classified as in remission or serologically active clinically quiescent (SACQ). The overall rate of agreement between these assessments was 81.2% (95% CI: 79.9, 82.9%) with a Cohen's kappa of 0.62 (0.55-0.69). Overall, 46 (9.1%) patients were classified as in remission/SACQ by rheumatologists but did not meet the 2021 DORIS criteria for remission. The main reasons for discrepancies were a clinical SLE Disease Activity Index (cSLEDAI) score >0 in 39 patients, a Physician Global Assessment score >0.5 in five patients, and prednisone >5 mg/day in another five patients. CONCLUSIONS The 2021 DORIS remission is an achievable target in clinical practice. There is substantial agreement between the DORIS definition and physician-judged remission. The discordance was mainly due to physicians classifying some patients with ongoing mild disease activity as in remission. Thus, the standardized DORIS definition should be used to define the target in a treat-to-target strategy for the management of SLE.
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Affiliation(s)
- Irene Altabás-González
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Íñigo Rúa-Figueroa
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Francisco Rubiño
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Coral Mouriño
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Group, Galicia Sur Health Research Institute, Vigo, Spain
| | | | - Raúl Menor-Almagro
- Rheumatology Department, Hospital Universitario de Jerez de la Frontera, Cádiz, Spain
| | | | - Eva Tomero
- Rheumatology Department, Hospital Universitario de la Princesa, Madrid, Spain
| | | | | | | | | | - Luís S Inês
- Rheumatology Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - Norman Jiménez
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - José María Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) Group, Galicia Sur Health Research Institute, Vigo, Spain
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Cruciani C, Zen M, Gatto M, Morand E, Doria A. Assessment of disease activity and damage in SLE: Are we there yet? Best Pract Res Clin Rheumatol 2023:101896. [PMID: 38044231 DOI: 10.1016/j.berh.2023.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023]
Abstract
Systemic Lupus Erythematosus is a systemic autoimmune disease characterized by a great heterogenicity in course and clinical manifestations. Although prognosis improved in the last decades of the 20th century, mortality remains higher than in the general population and uncontrolled disease activity and therapy-related adverse effects have been identified as major contributors to damage accrual and poor outcomes. Assessment of disease activity and damage in SLE represents a great challenge even to the expert rheumatologist. Global disease activity indices are tools developed to assess activity across multiple organ systems. Several disease activity indices have been developed over the years, each with its own strengths and weaknesses, and knowing them is essential for understanding research studies, such as clinical trials, in which they are used. Organ-specific activity indices have been developed concurrently to represent organ involvement such as glomerulonephritis, cutaneous and musculoskeletal lupus manifestations. Regarding damage, the SLICC/ACR damage index has proven to be an effective tool for damage accrual assessment, yet not devoid of drawbacks. This review provides an overview of the most frequently utilized indices developed for the assessment of activity and damage in SLE highlighting their pros and cons when applied to the research and clinical setting.
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Affiliation(s)
- Claudio Cruciani
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Margherita Zen
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Mariele Gatto
- Rheumatology Unit, Department of Clinical and Biological Sciences, University of Turin and Turin Mauriziano Hospital, Turin, Italy.
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University, Rheumatology Unit, Monash Health, Melbourne, Australia.
| | - Andrea Doria
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
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Andrade D, Tektonidou MG. Assessing disease activity and damage in antiphospholipid syndrome. Clin Immunol 2023; 255:109727. [PMID: 37558149 DOI: 10.1016/j.clim.2023.109727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/16/2023] [Indexed: 08/11/2023]
Abstract
Antiphospholipid syndrome (APS) has been characterized by a variety of vascular and pregnancy manifestations related to an interplay between thrombotic and inflammatory mechanisms, a progressive accrual of irreversible organ damage and increased morbidity and mortality rates, supporting a high need of optimal treatment approach. The lack of standardized outcome measures is a significant barrier in the design of clinical studies in APS. Disease activity (in principle reversible) and its distinction from disease damage (in principle irreversible) needs to be evaluated by validated scores for use in clinical trials but also in daily clinical practice in APS. A disease damage score in APS, the DIAPS score, has been developed and validated in external cohorts. The development of a disease activity score that will provide an accurate and reproducible rating of each disease domain, can help clinicians and researchers to comprehensively assess the activity of disease and the response to treatment, in an attempt to prevent future damage.
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Affiliation(s)
- Danieli Andrade
- Rheumatology Department, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil.
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Mendoza-Pinto C, Etchegaray-Morales I, Munguía-Realpozo P, Osorio-Peña ÁD, Méndez-Martínez S, Ramírez-Lara E, Zárate-Arellano D, Solis-Poblano JC, Ayón-Aguilar J, García-Carrasco M. Low disease activity state associated with fewer incident vertebral fractures in Mestizo women with systemic lupus erythematosus. Lupus 2023; 32:1328-1334. [PMID: 37705367 DOI: 10.1177/09612033231202878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Low disease activity state (LDAS) has been linked to a significant reduction in flares and damage accrual in patients with systemic lupus erythematosus (SLE); however, the effect of LDAS on the risk of vertebral fractures (VFs) in subjects with SLE is unknown, considering that low bone mineral density (BMD) and VF are frequent in SLE. OBJECTIVE to evaluate whether achieving LDAS ≥50% of the observation time prevents new VF and BMD changes in Mestizo women. METHODS We carried out a longitudinal, observational, and retrospective study. Mestizo women with SLE were included for a median of an 8-year follow-up. LDAS was described as Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score ≤4, prednisone ≤7.5 mg/day, and stable immunosuppressive therapies. BMD measurements and lateral thoracic and lumbar radiographs for a semiquantitative analysis for VF were assessed at baseline and during the follow-up. Uni- and multivariable interval-censored survival regression models were carried out. RESULTS We included 110 patients: 35 (31.8%) had new VF. A total of 56 patients (50.1%) achieved LDAS ≥50% of the time during the follow-up and achieved a significantly lesser risk of incident VF (HR = 0.16; 95% CI, 0.06-0.49). After adjusting by age, BMI, menopause, prevalent VF, baseline BMD, cumulative glucocorticoid use, and anti-osteoporotic therapy, LDAS-50 was significantly related to a decrease in the risk of a new VF (HR = 0.39; 95% CI, 0.16-0.98). There was no association between LDAS and BMD measurement changes. When only patients on LDAS but not in remission (n = 43) were evaluated for the risk of incident VF, both uni- and multivariate analyses were significant (HR = 0.12; 95 CI, 0.04-47; p = 0.001, and HR = 0.26; 95% CI, 0.7-0.88; p = 0.03). CONCLUSIONS LDAS ≥50% of the time was significantly associated with a diminished risk of new VF in Mestizo women with SLE, even in patients not in remission. However, LDAS did not help modify BMD changes over time.
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Affiliation(s)
- Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Ángel David Osorio-Peña
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | | | - Edith Ramírez-Lara
- Systemic Autoimmune Diseases Research Unit, Specialties Hospital UMAE- CIBIOR, Mexican Institute for Social Security, Puebla, Mexico
| | - Diana Zárate-Arellano
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
| | - Juan Carlos Solis-Poblano
- Department of Haematology, Specialties Hospital UMAE, Mexican Social Security Institute, Puebla, Mexico
| | - Jorge Ayón-Aguilar
- Coordination of Health Research, Mexican Social Security Institute, Puebla, Mexico
| | - Mario García-Carrasco
- Department of Rheumatology, Medicine School, Meritorious Autonomous University of Puebla, Puebla, Mexico
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9
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Smith EMD, Aggarwal A, Ainsworth J, Al-Abadi E, Avcin T, Bortey L, Burnham J, Ciurtin C, Hedrich CM, Kamphuis S, Lambert L, Levy DM, Lewandowski L, Maxwell N, Morand E, Ozen S, Pain CE, Ravelli A, Saad Magalhaes C, Pilkington C, Schonenberg-Meinema D, Scott C, Tullus K, Beresford MW. PReS-endorsed international childhood lupus T2T task force definition of childhood lupus low disease activity state (cLLDAS). Clin Immunol 2023; 250:109296. [PMID: 36934849 PMCID: PMC10500564 DOI: 10.1016/j.clim.2023.109296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE To achieve a consensus-based definition of Low Disease Activity (LDA) for use in cSLE trials. METHODS The International cSLE T2T Task Force, comprising of paediatric rheumatologists/nephrologists, and adult rheumatologists undertook a series of Delphi surveys/consensus meetings to discuss, refine, and vote upon cSLE LDA criteria. RESULTS The Task Force agreed that LDA should be based upon the adult-SLE Lupus Low Disease Activity State definition (LLDAS), with modifications to make it applicable to cSLE (cLLDAS). They agreed upon five cLLDAS criteria: (1) SLE Disease Activity Index (SLEDAI)-2 K ≤4, with no activity in major organ systems; (2) no new features of lupus disease activity compared with the last assessment; (3) Physician Global Assessment score of ≤1 (0-3 scale); (4) prednisolone dose of ≤0.15 mg/kg/day, 7.5 mg/day/maximum; while on (5) stable antimalarials, immunosuppressives, and biologics. CONCLUSIONS A cSLE-appropriate definition of cLLDAS has been generated, maintaining alignment with the adult-SLE definition to promote life-course research.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - J Ainsworth
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- Department of Paediatric Rheumatology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Slovenia
| | - L Bortey
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Burnham
- Department of Pediatric Rheumatology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - C Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Division of Medicine, University College London, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - S Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Lambert
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - D M Levy
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - L Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - N Maxwell
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, Australia
| | - S Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - C E Pain
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - A Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - C Saad Magalhaes
- Department of Pediatric Rheumatology, Botucatu Medical School, Sao Paulo State University, Sao Paulo, Brazil
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - D Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious diseases, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - C Scott
- Clinical Research Centre, Department of Pediatric Rheumatology, University of Cape Town, Cape Town, South Africa
| | - K Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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10
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Banjari M, Touma Z, Gladman DD. Improving measures of disease activity in systemic lupus erythematosus. Expert Rev Clin Immunol 2023; 19:193-202. [PMID: 36503376 DOI: 10.1080/1744666x.2023.2156339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a multisystem disease with varied manifestations and course. Variation in presentation among patients, and within the same patient, there may be varied manifestations over time. It has been difficult to measure the extent of disease activity accurately. Several investigators and groups have developed definitions of disease activity and methods to measure it. Consequently, there are currently several instruments to measure disease activity as well as damage in patients with SLE. AREAS COVERED This review covers currently available evidence on measures of disease activity in SLE. It discusses potential avenues for further development of new measures and the refinement of existing tools to improve disease activity measures in research and clinical care settings. EXPERT OPINION Given the complexity and heterogeneity of the disease, further work and tools are needed to assess disease activity better. Organ-specific measures for cutaneous, renal, and joint manifestations are needed for a detailed assessment of disease activity in conjunction with the use of disease generic tools (e.g. SLEDAI). New tools such as the SLE Disease Activity Index-Glucocorticoid Index (SLEDAI-2 KG) incorporating glucocorticoid doses to describe disease activity, SLE-DAS and SLEDAI-2 K RI-50 to record partial improvements could also be helpful.
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Affiliation(s)
- Maher Banjari
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zahi Touma
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Dvisiion of Rheumatology, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Dafna D Gladman
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Dvisiion of Rheumatology, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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11
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Jin Z, Chen Z, Pan W, Liu L, Wu M, Hu H, Ding X, Wei H, Zou Y, Qian X, Wang M, Wu J, Tao J, Tan J, Da Z, Zhang M, Li J, Feng X, Sun L. Comparison of Contributors to Mortality Differences in SLE Patients with Different Initial Disease Activity: A Larger Multicenter Cohort Study. J Clin Med 2023; 12:jcm12031061. [PMID: 36769709 PMCID: PMC9918091 DOI: 10.3390/jcm12031061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
To explore the etiology of risk factors and quantify the mortality differences in systemic lupus erythematosus (SLE) patients with different initial disease activity. The Jiangsu Lupus database was established by collecting medical records from first-hospitalized SLE patients during 1999-2009 from 26 centers in Jiangsu province, China, and their survival status every five years. The initial SLEDAI scores [high (>12) vs. low-moderate (≤12)] differences in mortality attributable to risk factors were quantified using population attributable fraction (PAF), relative attributable risk (RAR) and adjusted relative risk (ARR). Among 2446 SLE patients, 83 and 176 deaths were observed in the low-moderate and high activity groups, with mortality rates of 7.7 and 14.0 per 1000 person years, respectively. Anemia was the leading contributor to mortality, with PAFs of 40.4 and 37.5 in the low-moderate and high activity groups, respectively, and explained 23.2% of the mortality differences with an ARR of 1.66 between the two groups. Cardiopulmonary involvement caused the highest PAFs in the low-moderate (20.5%) and high activity (13.6%) groups, explaining 18.3% of the mortality differences. The combination of anemia and cardiopulmonary involvement had the highest RAR, causing 39.8% of the mortality differences (ARR = 1.52) between the two groups. In addition, hypoalbuminemia and a decrease in the creatinine clearance rate accounted for 20-30% of deaths and explained 10-20% of the mortality differences between the two groups, while antimalarial drug nonuse accounted for about 35% of deaths and explained 3.6% of the mortality differences. Anemia, cardiopulmonary involvement and hypoalbuminemia may cause substantial mortality differences across disease activity states, suggesting additional strategies beyond disease activity assessment to monitor SLE outcomes.
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Affiliation(s)
- Ziyi Jin
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Zheng Chen
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Wenyou Pan
- Department of Rheumatology, Huai’an First People’s Hospital, Huai’an 223001, China
| | - Lin Liu
- Department of Rheumatology, Xuzhou Central Hospital, Xuzhou 221008, China
| | - Min Wu
- Department of Rheumatology, The Third Affiliated Hospital of Soochow University, Changzhou 213003, China
| | - Huaixia Hu
- Department of Rheumatology, Lianyungang Second People’s Hospital, Lianyungang 222000, China
| | - Xiang Ding
- Department of Rheumatology, Lianyungang First People’s Hospital, Lianyungang 222002, China
| | - Hua Wei
- Department of Rheumatology, Northern Jiangsu People’s Hospital, Yangzhou 225007, China
| | - Yaohong Zou
- Department of Rheumatology, Wuxi People’s Hospital, Wuxi 214028, China
| | - Xian Qian
- Department of Rheumatology, Jiangsu Province Hospital of TCM, Nanjing 210004, China
| | - Meimei Wang
- Department of Rheumatology, Southeast University Zhongda Hospital, Nanjing 210009, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, Suzhou 215005, China
| | - Juan Tao
- Department of Rheumatology, Wuxi TCM Hospital, Wuxi 214177, China
| | - Jun Tan
- Department of Rheumatology, Zhenjiang First People’s Hospital, Zhenjiang 212050, China
| | - Zhanyun Da
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Miaojia Zhang
- Department of Rheumatology, Jiangsu Province Hospital, Nanjing 210029, China
| | - Jing Li
- Department of Rheumatology, Affiliated Hospital of Jiangsu University, Zhenjiang 212050, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
- Correspondence: (X.F.); (L.S.); Tel.: +86-25-6818-2422(L.S.); Fax: +86-25-6818-2428(L.S.)
| | - Lingyun Sun
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
- Correspondence: (X.F.); (L.S.); Tel.: +86-25-6818-2422(L.S.); Fax: +86-25-6818-2428(L.S.)
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12
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Ugarte-Gil MF, Fuentes-Silva Y, Pimentel-Quiroz VR, Pons-Estel GJ, Quintana R, Pons-Estel BA, Alarcón GS. Global excellence in rheumatology in Latin America: The case of systemic lupus erythematosus. Front Med (Lausanne) 2023; 9:988191. [PMID: 36714141 PMCID: PMC9874001 DOI: 10.3389/fmed.2022.988191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
Systemic lupus erythematosus (SLE) affects more severely non-White populations, due to their genetic background and sociodemographic characteristics. Several studies have evaluated Latin American SLE patients to determine their genetic and clinical characteristics as well as prognostic factors; these studies have not only allowed the development of treatment guidelines aimed at the region but also to support regional and global projects. Additionally, educational activities in Spanish and Portuguese have been started to reduce our patients' health illiteracy. Despite the relatively low research output from Latin American countries, we consider that studies from our region coupled with the networks developed to increase our capabilities, could be a model for other rare autoimmune diseases.
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Affiliation(s)
- Manuel F. Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, School of Medicine, Universidad Científica del Sur, Lima, Peru,Department Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru,*Correspondence: Manuel F. Ugarte-Gil,
| | | | - Victor R. Pimentel-Quiroz
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, School of Medicine, Universidad Científica del Sur, Lima, Peru,Department Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Guillermo J. Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Rosana Quintana
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Bernardo A. Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Graciela S. Alarcón
- Marnix E. Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, United States,Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
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13
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Wallace DJ. Can lupus low disease activity state predict mortality in patients with SLE? THE LANCET RHEUMATOLOGY 2022. [DOI: 10.1016/s2665-9913(22)00310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Kandane-Rathnayake R, Golder V, Louthrenoo W, Chen YH, Cho J, Lateef A, Hamijoyo L, Luo SF, Wu YJJ, Navarra SV, Zamora L, Li Z, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake BMDB, Chan M, Kikuchi J, Takeuchi T, Bae SC, Oon S, O'Neill S, Goldblatt F, Ng KPL, Law A, Tugnet N, Kumar S, Tee C, Tee M, Ohkubo N, Tanaka Y, Yu D, Karyekar CS, Sing Lau C, Monk JA, Nikpour M, Hoi A, Morand EF. Lupus low disease activity state and remission and risk of mortality in patients with systemic lupus erythematosus: a prospective, multinational, longitudinal cohort study. THE LANCET. RHEUMATOLOGY 2022; 4:e822-e830. [PMID: 38261390 DOI: 10.1016/s2665-9913(22)00304-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Treat-to-target goals for patients with systemic lupus erythematosus (SLE) have been validated to protect against organ damage and to improve quality of life. We aimed to investigate the association between lupus low disease activity state (LLDAS) and remission and risk of mortality in patients with SLE. We hypothesised that LLDAS has a protective association with mortality risk. METHODS In this prospective, multinational, longitudinal cohort study, we used data from patients with SLE in the Asia Pacific Lupus Collaboration cohort collected between May 1, 2013, and Dec 31, 2020. Eligible patients were adults (aged ≥18 years) who met either the 1997 American College of Rheumatology modified classification criteria for SLE or the 2012 Systemic Lupus International Collaborating Clinics classification criteria. The primary outcome was all-cause mortality, and LLDAS, remission, and variations of remission with lower glucocorticoid thresholds were the primary exposure variables. Survival analyses were used to examine longitudinal associations between these endpoints and risk of mortality. This study is registered with ClinicalTrials.gov, NCT03138941. FINDINGS Among a total of 4106 patients in the cohort, 3811 (92·8%) patients were included in the final analysis (median follow-up 2·8 years [IQR 1·0-5·3]; 3509 [92·1%] women and 302 [7·9%] men), of whom 80 died during the observation period (crude mortality rate 6·4 deaths per 1000 person-years). LLDAS was attained at least once in 43 (53·8%) of 80 participants who died and in 3035 (81·3%) of 3731 participants who were alive at the end of the study (p<0·0001); 22 (27·5%) participants who died versus 1966 (52·7%) who were alive at the end of the study attained LLDAS for at least 50% of observed time (p<0·0001). Remission was attained by 32 (40·0%) of 80 who died and in 2403 (64·4%) of 3731 participants who were alive at the end of the study (p<0·0001); 14 (17·5%) participants who died versus 1389 (37·2%) who were alive at the end of the study attained remission for at least 50% of observed time (p<0·0001). LLDAS for at least 50% of observed time (adjusted hazard ratio 0·51 [95% CI 0·31-0·85]; p=0·010) and remission for at least 50% of observed time (0·52 [0·29-0·93]; p=0·027) were associated with reduced risk of mortality. Modifying the remission glucocorticoid threshold (<5·0 mg/day prednisolone) was more protective against mortality than current remission definitions (0·31 [0·12-0·77]; p=0·012), and glucocorticoid-free remission was the most protective (0·13 [0·02-0·96]; p=0·046). INTERPRETATION LLDAS significantly reduced the risk of mortality in patients with SLE. Remission did not further reduce the risk of mortality compared with LLDAS, unless lower glucocorticoid thresholds were used. FUNDING The Asia-Pacific Lupus Collaboration received funding from Janssen, Bristol Myers Squibb, Eli Lilly, and UCB for this study.
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Affiliation(s)
| | - Vera Golder
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiacai Cho
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Laniyati Hamijoyo
- Department of Internal Medicine, Faculty of Medicine, University of Padjadjaran, Sumedang, Indonesia
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yeong-Jian J Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Sandra V Navarra
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Bejing, China
| | - Sargunan Sockalingam
- Department of Rheumatology and Immunology, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Yanjie Hao
- Institute of Rheumatology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Institute of Rheumatology, Peking University First Hospital, Beijing, China
| | | | | | - Jun Kikuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan; Saitama Medical University, Saitama, Japan
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang University Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - Shereen Oon
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, VIC, Australia
| | - Sean O'Neill
- Department of Medicine, University of New South Wales, Kensington, NSW, Australia; Musculoskeletal flagship, University of Sydney, Camperdown, NSW, Australia
| | - Fiona Goldblatt
- Royal Adelaide Hospital and Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Annie Law
- Singapore General Hospital, Singapore
| | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | - Sunil Kumar
- Department of Rheumatology, Middlemore Hospital, Auckland, New Zealand
| | - Cherica Tee
- Department of Medicine, University of the Philippines, Quezon City, Philippines
| | - Michael Tee
- Department of Medicine, University of the Philippines, Quezon City, Philippines
| | - Naoaki Ohkubo
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Chak Sing Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong Special Administrative Region, China
| | - Julie A Monk
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Mandana Nikpour
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, VIC, Australia
| | - Alberta Hoi
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, Australia.
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15
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Peripheral immunophenotypes associated with the flare in the systemic lupus erythematosus patients with low disease activity state. Clin Immunol 2022; 245:109166. [DOI: 10.1016/j.clim.2022.109166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/08/2021] [Accepted: 10/14/2022] [Indexed: 11/22/2022]
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16
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Ugarte-Gil MF, Hanly J, Urowitz M, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey-Goldman R, Manzi S, Jönsen A, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Lim S, Inanc M, Kalunian K, Jacobsen S, Peschken C, Kamen DL, Askanase A, Pons-Estel BA, Alarcón GS. Remission and low disease activity (LDA) prevent damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2022; 81:1541-1548. [PMID: 35944946 PMCID: PMC10353886 DOI: 10.1136/ard-2022-222487] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/13/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the independent impact of different definitions of remission and low disease activity (LDA) on damage accrual. METHODS Patients with ≥2 annual assessments from a longitudinal multinational inception lupus cohort were studied. Five mutually exclusive disease activity states were defined: remission off-treatment: clinical Systemic Lupus Erythematosus Disease Activity Index (cSLEDAI)-2K=0, without prednisone or immunosuppressants; remission on-treatment: cSLEDAI-2K score=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; low disease activity Toronto cohort (LDA-TC): cSLEDAI-2K score of ≤2, without prednisone or immunosuppressants; modified lupus low disease activity (mLLDAS): Systemic Lupus Erythematosus Disease Activity Index-2K score of 4 with no activity in major organ/systems, no new disease activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants; active: all remaining visits. Only the most stringent definition was used per visit. Antimalarials were allowed in all. The proportion of time that patients were in a specific state at each visit since cohort entry was determined. Damage accrual was ascertained with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Univariable and multivariable generalised estimated equation negative binomial regression models were used. Time-dependent covariates were determined at the same annual visit as the disease activity state but the SDI at the subsequent visit. RESULTS There were 1652 patients, 1464 (88.6%) female, mean age at diagnosis 34.2 (SD 13.4) years and mean follow-up time of 7.7 (SD 4.8) years. Being in remission off-treatment, remission on-treatment, LDA-TC and mLLDAS (per 25% increase) were each associated with a lower probability of damage accrual (remission off-treatment: incidence rate ratio (IRR)=0.75, 95% CI 0.70 to 0.81; remission on-treatment: IRR=0.68, 95% CI 0.62 to 0.75; LDA: IRR=0.79, 95% CI 0.68 to 0.92; and mLLDAS: IRR=0.76, 95% CI 0.65 to 0.89)). CONCLUSIONS Remission on-treatment and off-treatment, LDA-TC and mLLDAS were associated with less damage accrual, even adjusting for possible confounders and effect modifiers.
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Affiliation(s)
- Manuel Francisco Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistemicas, Universidad Cientifica del Sur, Lima, Peru
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - John Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray Urowitz
- Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
- Hanyang University Institute for Rheumatology Research and Hanyang University Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - Juanita Romero-Diaz
- Inmunología y Reumatología, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Jorge Sanchez-Guerrero
- Inmunología y Reumatología, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
- Sinai Health System and University Health Network, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Sasha Bernatsky
- Divisions of Rheumatology and Clinical Epidemiology, McGill University, Montreal, Québec, Canada
| | - Ann Elaine Clarke
- Division of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars Sinai/David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | | | - Joan T Merrill
- Department of Clinical Pathology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Paul R Fortin
- Centre ARThrite, Rheumatology, CHU de Québec - Université Laval, Quebec, Quebec, Canada
| | - Dafna D Gladman
- Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Faculty of Biology Medicine and Health, Manchester Academic Health Sciences Center, University of Manchester, Manchester, UK
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Mary Anne Dooley
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rosalind Ramsey-Goldman
- Department of Medicine, Division of Rheumatology, Northwestern University and Feinberg School of Medicine, Chicago, Illinois, USA
| | - Susan Manzi
- Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | | | - Cynthia Aranow
- Northwell Health Manhasset, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Meggan Mackay
- Northwell Health Manhasset, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. BioCruces Bizkaia Health Research Institute, University of the Basque Country, Balakaldo, Spain
| | - Sam Lim
- School of Medicine, Division of Rheumatology, Emory University, Atlanta, Georgia, USA
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Capa, Istanbul, Turkey
| | - Ken Kalunian
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Søren Jacobsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Christine Peschken
- Departments of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Diane L Kamen
- Division of Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anca Askanase
- Columbia University Irving Medical Center, New York, New York, USA
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Graciela S Alarcón
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
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17
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Gioti O, Chavatza K, Nikoloudaki M, Katechis S, Bertsias G, Boumpas DT, Fanouriakis A. Residual disease activity and treatment intensification in systemic lupus erythematosus: A cross-sectional study to quantify the need for new therapies. Lupus 2022; 31:1726-1734. [PMID: 36169280 DOI: 10.1177/09612033221129776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The proportion of SLE patients with residual disease activity in routine settings is variable. We assessed disease activity state in patients during their most recent visit, and whether patients with residual activity were offered therapy intensification. METHODS Cross-sectional study of consecutive lupus patients in three tertiary centers. Patients were categorized as: i) remission off-therapy, ii) remission on-therapy, iii) low disease activity, and iv) non-optimally controlled disease. Multivariable regression identified factors associated with treatment intensification and ROC analysis calculated the accuracy of SLEDAI-2K to predict this intensification. RESULTS Three hundred and thirty-two patients were included [93.1% female, mean (SD) age 48.5 (14.7) years, median (IQR) disease duration 6.5 (12.4) years]. Mean (SD) total and clinical SLEDAI at last visit were 3.7 (3.0) and 3.0 (2.9), respectively. Although 23.2% of patients were in remission, 40.1% were categorized as non-optimally controlled disease (79.2% due to SLEDAI-2K > 4), but less than 50% of them were offered therapy intensification. Proteinuria (OR 6.78, 95% CI 2.06-22.25), arthritis (OR 5.48, 95% CI 3.20-9.40), and rash (OR 3.23, 95% CI 1.81-5.75) were associated with intensification of therapy, but the accuracy of either total or clinical SLEDAI to predict it was moderate (ROC area under the curve 0.761 and 0.779, respectively). CONCLUSIONS About 40% of patients have evidence of residual disease activity and could qualify for novel treatments. Most treatment changes were triggered by active renal, joint, and skin disease, whereas the predictive value of SLEDAI-2K as a metric of disease activity was modest.
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Affiliation(s)
- Ourania Gioti
- Department of Rheumatology, "Asklepieio" General Hospital, Athens, Greece
| | - Katerina Chavatza
- "Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Nikoloudaki
- Rheumatology, Clinical Immunology and Allergy, 37778University of Crete School of Medicine, Heraklion, Greece
| | - Spyridon Katechis
- Department of Rheumatology, "Asklepieio" General Hospital, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, 37778University of Crete School of Medicine, Heraklion, Greece.,Institute of Molecular Biology and Biotechnology, Foundation of Research and Technology-Hellas, Heraklion, Greece
| | - Dimitrios T Boumpas
- "Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Department of Rheumatology, "Asklepieio" General Hospital, Athens, Greece.,"Attikon" University Hospital of Athens, Rheumatology and Clinical Immunology, Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
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18
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Zen M, Gatto M, Doria A. Defining the targets in SLE management: insights and unmet gaps. Ann Rheum Dis 2022; 81:1483-1485. [PMID: 36008131 DOI: 10.1136/ard-2022-222991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/17/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Margherita Zen
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, University of Padua, Padova, Italy
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19
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Altabás-González I, Rúa-Figueroa I, Rubiño F, Mouriño Rodríguez C, Hernández-Rodríguez I, Menor Almagro R, Uriarte Isacelaya E, Tomero Muriel E, Salman-Monte TC, Carrión-Barberà I, Galindo M, Rodríguez Almaraz EM, Jiménez N, Inês L, Pego-Reigosa JM. Does expert opinion match the definition of lupus low disease activity state? Prospective analysis of 500 patients from a Spanish multicentre cohort. Rheumatology (Oxford) 2022; 62:1162-1169. [PMID: 35961050 PMCID: PMC9977118 DOI: 10.1093/rheumatology/keac462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/03/2022] [Accepted: 08/06/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To apply the lupus low disease activity state (LLDAS) definition within a large cohort of patients and to assess the agreement between the LLDAS and the physician's subjective evaluation of lupus activity. METHODS We conducted a cross-sectional analysis of a prospective multicentre study of SLE patients. We applied the LLDAS and assessed whether there was agreement with the clinical status according to the physician's opinion. RESULTS A total of 508 patients [92% women; mean age 50.4 years (s.d. 3.7)] were recruited and 304 (62.7%) patients were in the LLDAS. According to physician assessment, 430 (86.1%) patients were classified as remission or low activity. Overall agreement between both evaluations was 71.4% (95% CI: 70.1, 70.5) with a Cohen's κ of 0.3 [interquartile range (IQR) 0.22-0.37]. Most cases (96.1%) in the LLDAS were classified as remission or low activity by the expert. Of the patients who did not fulfil the LLDAS, 126 (70.4%) were classified as having remission/low disease activity. The main reasons for these discrepancies were the presence of new manifestations compared with the previous visit and a SLEDAI 2K score >4, mainly based on serological activity. CONCLUSIONS Almost two-thirds of SLE patients were in the LLDAS. There was a fair correlation between the LLDAS and the physician's evaluation. This agreement improves for patients fulfilling the LLDAS criteria. The discordance between both at defining lupus low activity, the demonstrated association of the LLDAS with better outcomes and the fact that the LLDAS is more stringent than the physician's opinion imply that we should use the LLDAS as a treat-to-target goal.
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Affiliation(s)
- Irene Altabás-González
- Correspondence to: Irene Altabás-González, Rheumatology Department, Complejo Hospitalario Universitario de Vigo, Galicia Sur Health Research Institute, Alto do Meixoeiro s/n, 36200 Vigo. Spain. E-mail:
| | - Iñigo Rúa-Figueroa
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria
| | - Francisco Rubiño
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria
| | - Coral Mouriño Rodríguez
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo,Investigation in Rheumatology and Immune-Mediated Diseases Group, Galicia Sur Health Research Institute, Vigo
| | | | - Raul Menor Almagro
- Rheumatology Department, Hospital Universitario de Jerez de la Frontera, Cádiz
| | | | - Eva Tomero Muriel
- Rheumatology Department, Hospital Universitario de la Princesa, Madrid
| | | | | | - Maria Galindo
- Rheumatology Department, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | | | - Norman Jiménez
- Investigation in Rheumatology and Immune-Mediated Diseases Group, Galicia Sur Health Research Institute, Vigo
| | - Luis Inês
- Rheumatology Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - José Maria Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo,Investigation in Rheumatology and Immune-Mediated Diseases Group, Galicia Sur Health Research Institute, Vigo
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20
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Samões B, Zen M, Abelha-Aleixo J, Gatto M, Doria A. Caveats and pitfalls in defining low disease activity in systemic lupus erythematosus. Autoimmun Rev 2022; 21:103165. [PMID: 35931316 DOI: 10.1016/j.autrev.2022.103165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
The treat-to-target strategy has been recently suggested in the management of Systemic Lupus Erythematosus (SLE). Lupus Low Disease Activity State (LLDAS) and Definitions Of Remission In SLE (DORIS) remission were outlined as two concentric targets. The achievement of LLDAS was shown to be associated with lower frequency of SLE flare, decreased damage progression, better quality of life, and reduced mortality. In addition, LLDAS has successfully been tested in post-hoc analyses of a number of randomized controlled trials. However, it has been recently underlined that LLDAS includes a high proportion of patients in remission, raising the question if these endpoints are sufficiently distinct to consider their separation clinically relevant. Some studies suggest that the protective effect of LLDAS on damage might be due to the inclusion of patients who are in remission. Notably, clinical low disease activity (LDA) seems to be uncommon in SLE due to the relapsing-remitting pattern of the disease, in which low level of activity only occurs transiently. Moreover, since the domains included in LLDAS have several limitations, such as the use of a binomial disease activity index, the exclusion of some mild manifestations and the consideration of items subjected to variability (physician global assessment and glucocorticoids dose), not all patients in LDA are adequately represented by LLDAS.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Joana Abelha-Aleixo
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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21
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Piga M, Chessa E, Morand EF, Ugarte-Gil MF, Tektonidou M, van Vollenhoven R, Petri M, Arnaud L. Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus: the PISCOS study. THE LANCET. RHEUMATOLOGY 2022; 4:e441-e449. [PMID: 38293958 DOI: 10.1016/s2665-9913(22)00107-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 12/13/2022]
Abstract
The Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus (PISCOS) study aimed to obtain an evidence-based and expert-based consensus standardisation of the Physician Global Assessment (PGA) scoring of disease activity in systemic lupus erythematosus (SLE). An international panel of 79 SLE experts participated in a three-round Delphi consensus process, in which 41 statements related to the PGA in SLE were rated, using a 0 (strongly disagree) to 10 (strongly agree) numerical rating scale. Statements with agreement of 75% or greater were selected and further validated by the expert panel. Consensus was reached on 27 statements, grouped in 14 recommendations, for the use of the PGA in SLE, design of the PGA scale, practical considerations for PGA scoring, and the relationship between PGA values and levels of disease activity. Among these recommendations, the expert panel agreed that the PGA should consist of a 0-3 visual analogue scale for measuring disease activity in patients with SLE in the preceding month. The PGA is intended to rate the overall disease activity, taking into account the severity of active manifestations and clinical laboratory results, but excluding organ damage, serology, and subjective findings unrelated to disease activity. The PGA scale ranges from "no disease activity" (0) to the "most severe disease activity" (3) and incorporates the values 1 and 2 as inner markers to categorise disease activity as mild (≥0·5 to 1), moderate (>1 and ≤2) and severe (>2 to 3). Only experienced physicians can rate the PGA, and it should be preferably scored by the same rater at each visit. The PISCOS results will allow for increased homogeneity and reliability of PGA ratings in routine clinical practice, definitions of remission and low disease activity, and future SLE trials.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, Cagliari, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, AOU University Clinic and University of Cagliari, Cagliari, Italy
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, VIC, Australia
| | - Manuel F Ugarte-Gil
- School of Medicine, Universidad Científica del Sur and Rheumatology Department, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Maria Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ronald van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, Netherlands
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; Centre National de Référence des Maladies Systémiques et Autoimmunes Rares Est Sud-Ouest (RESO), Strasbourg, France.
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22
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Sun F, Zhao L, Wang H, Zhang D, Chen J, Wang X, Li T, Ye S. Risk factors of disease flares in a Chinese lupus cohort with low-grade disease activity. Lupus Sci Med 2022; 9:e000657. [PMID: 35606018 PMCID: PMC9125751 DOI: 10.1136/lupus-2022-000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Recurrent disease flare is one of the key problems in lupus patients. A Chinese Flare-Prevention Lupus Initiative Cohort (FLIC) was established. Risk factors of disease flare were evaluated accordingly. METHODS Patients with low-grade disease activity (the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI) =≤6, daily prednisone ≤20 mg, no British Isles Lupus Assessment Group A or no more than one B organ domain score) from January 2014 to August 2020 were included in the FLIC. Disease flares were defined by the modified SELENA--SLEDAI Flare Index. Low disease activity status (LDAS) and remission were also assessed. The cumulative flare rate was estimated by an event per 100 person-years analysis. Cox proportional hazards models were performed to identify risk factors of subsequent disease flares after adjusting clinical confounders. Survival was assessed with the Kaplan-Meier method. RESULTS 448 eligible patients with low-grade disease activity were included in FLIC. During a mean follow-up of 30.4 months, 170 patients flared. The cumulative lupus flare rate was 22.2 events per 100 patient-years. Compared with patients without flare, those with lupus flares were taking more prednisone, had higher disease activity index and with less patients attained LDAS/remission at baseline. They also had higher rates of antiphospholipid antibodies (aPLs) and antiribosomal P antibody. Cox regression analysis confirmed that attainment of either LDAS or remission at baseline were independent protective factors against subsequent disease flare (LDAS but not in remission: HR 0.58, 95% CI 0.38~0.88; remission: HR 0.46, 95% CI 0.30~0.69), while aPL was a risk factor of lupus flares (HR 1.95, 95% CI 1.36~2.78). Kaplan-Meier curves indicated that attaining LDAS or remission and absence of aPL at baseline had the least flare risk. CONCLUSIONS In our real-world cohort study, not attaining LDAS or remission at baseline and aPL positivity was associated with higher risk of disease flares in patients with low-grade SLE.
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Affiliation(s)
- Fangfang Sun
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Liling Zhao
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Haiting Wang
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Danting Zhang
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Jie Chen
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Xiaodong Wang
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Ting Li
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
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23
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Porta SV, Ugarte-Gil MF, García-de la Torre I, Bonfá E, Gómez-Puerta JA, Arnaud L, Cardiel MH, Alarcón GS, Pons-Estel BA, Pons-Estel G. Controversies in Systemic Lupus Erythematosus: Are We Treating Our Patients Adequately? J Clin Rheumatol 2022; 28:e651-e658. [PMID: 34897194 DOI: 10.1097/rhu.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.
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Affiliation(s)
- Sabrina Valeria Porta
- From the Rheumatology Department, J. M. Ramos Mejía Hospital, Buenos Aires, Argentina
| | - Manuel F Ugarte-Gil
- Universidad Científica del Sur, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Ignacio García-de la Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente de la Secretaría de Salud, Universidad de Guadalajara, Guadalajara, México
| | - Eloísa Bonfá
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, National Reference Center for Rare Auto-immune and Systemic Diseases (CRMR RESO); Strasbourg, France
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, Mich, México
| | - Graciela S Alarcón
- Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL; Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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24
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Ugarte-Gil MF, Gamboa-Cardenas RV, Reátegui-Sokolova C, Pimentel-Quiroz VR, Medina M, Elera-Fitzcarrald C, Zevallos F, Pastor-Asurza CA, Lofland J, Zazzetti F, Karyekar CS, Alarcón GS, Perich-Campos RA. LLDAS (lupus low disease activity state) and/or remission are associated with less damage accrual in patients with systemic lupus erythematosus from a primarily Mestizo population: data from the Almenara Lupus Cohort. Lupus Sci Med 2022; 9:9/1/e000616. [PMID: 35193948 PMCID: PMC8867305 DOI: 10.1136/lupus-2021-000616] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/04/2022] [Indexed: 02/01/2023]
Abstract
Objective To determine if achieving lupus low disease activity state (LLDAS) or remission prevents damage accrual in a primarily Mestizo population. Methods Patients with SLE from a single-centre cohort with at least two visits occurring every 6 months were included. The definitions used were the following: for remission, the 2021 Definition Of Remission In SLE; and for LLDAS, the Asia Pacific Lupus Collaboration. Damage accrual was ascertained with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Univariable and three multivariable interval-censored survival regression models were done: (1) remission versus not on remission; (2) LLDAS/remission versus active; and (3) remission and LLDAS (not on remission) versus active. Three similar multivariable models were also examined considering the duration on each state. Possible confounders included in these analyses were gender, age at diagnosis, socioeconomic status, educational level, disease duration, antimalarial use and SDI at baseline. Results Two hundred and eighty-one patients were included. Eighty-three patients (29.5%) showed increased SDI during the follow-up. In the analyses of remission, being on remission predicted a lower probability of damage (HR=0.456; 95% CI 0.256 to 0.826; p=0.010). In the analyses of LLDAS/remission, being on LLDAS/remission predicted a lower damage (HR=0.503; 95% CI 0.260 to 0.975; p=0.042). When both states were considered, remission but not LLDAS (not on remission) predicted a lower probability of damage (HR=0.423; 95% CI 0.212 to 0.846; p=0.015 and HR=0.878; 95% CI 0.369 to 2.087; p=0.768, respectively). When the duration of these states was taken into account, remission, LLDAS/remission and LLDAS not on remission were associated with a lower probability of damage accrual. Conclusions LLDAS and/or remission were associated with a lower probability of damage accrual.
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Affiliation(s)
- Manuel Francisco Ugarte-Gil
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru .,Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
| | - Rocio Violeta Gamboa-Cardenas
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
| | - Cristina Reátegui-Sokolova
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,Unidad de Investigación Para La Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Victor Román Pimentel-Quiroz
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,Unidad de Investigación Para La Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Mariela Medina
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Claudia Elera-Fitzcarrald
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
| | - Francisco Zevallos
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Cesar Augusto Pastor-Asurza
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | | | | | - Graciela S Alarcón
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Risto Alfredo Perich-Campos
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru.,School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
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25
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Hao Y, Oon S, Ji L, Gao D, Fan Y, Geng Y, Zhang X, Li G, Morand EF, Nikpour M, Zhang Z. Determinants and protective associations of the lupus low disease activity state in a prospective Chinese cohort. Clin Rheumatol 2022; 41:357-366. [PMID: 34595670 PMCID: PMC8782788 DOI: 10.1007/s10067-021-05940-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the frequency and determinants of achieving the lupus low disease activity state (LLDAS), and the effect of LLDAS attainment on disease flare and damage accrual in a prospective, single-center cohort of Chinese lupus patients. METHODS Baseline and follow-up data from consecutive patients at the Peking University First Hospital were collected from January 2017 to June 2020. RESULTS A total of 185 patients were enrolled, with median (range) disease duration at enrolment of 2.3 (0.8-7.7) years, and median follow-up of 2.2 (1.0-2.9) years. By the end of the study, 139 (75.1%) patients had achieved LLDAS at least once; 82 (44.3%) patients achieved LLDAS for ≥ 50% of observations. Multivariable logistic regression analysis showed that 24-h urinary total protein (UTP; per g) (OR = 0.447, 95%CI [0.207-0.968], p = 0.041), serum creatinine (Scr; per 10 µmol/L) (OR = 0.72, 95%CI [0.52-0.99], p = 0.040), and C3 level (per 100 mg/L) (OR = 1.60, 95%CI [1.18-2.17], p = 0.003) at recruitment had independent negative associations with achieving LLDAS for ≥ 50% of observations. Kaplan-Meier analyses showed a significant reduction in flare rate with increased proportion of time in LLDAS. Attainment of LLDAS in at least 50% of observations was an independent protective factor for damage accrual (OR = 0.19, 95%CI [0.04-0.99], p = 0.049). CONCLUSIONS In this prospective Chinese cohort, LLDAS was an attainable goal in clinical practice. Nephritis-related markers (UTP and Scr) and C3 level at recruitment negatively influenced achievement of LLDAS. LLDAS achievement was significantly protective from flare and damage accrual. KEY POINTS • Low disease activity status (LLDAS) is an achievable target during SLE treatment in China. Urine protein, serum creatinine, and C3 level at recruitment independently affect LLDAS achievement in this group of Chinese lupus patients. • As a treatment target, LLDAS achievement has a highly protective effect for preventing flare and damage accrual, especially in case of achieving LLDAS for ≥ 50% of observations. • The present results further highlight the practical significance of treat-to-target principle in SLE management (T2T/SLE) and the needs for promoting the application of T2T/SLE in clinical practice as well as exploring the concrete implement strategy.
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Affiliation(s)
- Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Shereen Oon
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Rheumatology, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Dai Gao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | | | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Eric F Morand
- Monash University, Faculty of Medicine, Nursing and Health Sciences, Melbourne, Australia
| | - Mandana Nikpour
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Rheumatology, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - ZhuoLi Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China.
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26
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Treat-to-target in systemic lupus erythematosus: advancing towards its implementation. Nat Rev Rheumatol 2022; 18:146-157. [PMID: 35039665 DOI: 10.1038/s41584-021-00739-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 02/08/2023]
Abstract
The treat-to-target (T2T) concept has improved outcomes for patients with diabetes, hypertension and rheumatoid arthritis. This therapeutic strategy involves choosing a well-defined, relevant target, taking therapeutic steps, evaluating whether the target has been achieved, and taking action if it has not. The T2T principle has been embraced by systemic lupus erythematosus (SLE) experts, but measurable and achievable outcomes, and therapeutic options, are needed to make this approach possible in practice. Considerable evidence has been generated regarding meaningful 'state' outcomes for SLE. Low disease activity has been defined and studied, and the most aspirational goal, remission, has been defined by the Definition of Remission in SLE task force. By contrast, current therapeutic options in SLE are limited, and more effective and safer therapies are urgently needed. Fortunately, clinical trial activity in SLE has been unprecedented, and encouraging results have been seen for novel therapies, including biologic and small-molecule agents. Thus, with the expected advent of such treatments, it is likely that sufficiently diverse therapies for SLE will be available in the foreseeable future, allowing the routine implementation of T2T approaches in the care of patients with SLE.
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27
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Kikuchi J, Hanaoka H, Saito S, Oshige T, Hiramoto K, Kaneko Y, Takeuchi T. Lupus low disease activity state within 12 months is associated with favourable outcomes in severely active systemic lupus erythematosus. Rheumatology (Oxford) 2022; 61:3777-3791. [PMID: 35015824 DOI: 10.1093/rheumatology/keac002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To demonstrate the significance of the time to attain lupus low disease activity state (LLDAS) after remission induction therapy in patients with severely active systemic lupus erythematosus (SLE). METHODS We enrolled 79 patients starting prednisolone ≥0.4 mg/kg/day for active lupus with a British Isles Lupus Assessment Group 2004 index of A ≥ 1 or B ≥ 2, or for severe flare based on the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI). The time to LLDAS attainment was divided into ≤6, 6-12, and >12 months and non-LLDAS; associations between the timing of LLDAS and flares, damage accrual, and ≥50% LLDAS attainment were examined. RESULTS The mean SLEDAI was 17; median starting dose of prednisolone, 0.95 mg/kg/day; and mean observational period, 39.7 months. Six (7.6%) and 41 (51.9%) patients achieved LLDAS within 6 and 12 months. Patients with a shorter time to LLDAS achievement were more likely to spend ≥50% of the time in LLDAS and had a lower cumulative prednisolone dose; no differences were observed in damage accrual. Patients requiring longer than 12 months to achieve LLDAS had a higher prevalence of thrombocytopenia and those with non-LLDAS had lower renal function and a higher starting dose of prednisolone and steroid pulse therapy than those who achieved LLDAS within 12 months. CONCLUSION Achieving LLDAS within 12 months of induction therapy may be favourable in patients with severely active SLE. The low frequency of LLDAS attainment in high-risk populations highlights the need for a new strategy for SLE treatment.
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Affiliation(s)
- Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Hironari Hanaoka
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Shuntaro Saito
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tatsuhiro Oshige
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kazuoto Hiramoto
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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28
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Jiang N, Li M, Zhang H, Duan X, Li X, Fang Y, Li H, Yang P, Luo H, Wang Y, Peng L, Zhao J, Wu C, Wang Q, Tian X, Zhao Y, Zeng X. Sirolimus versus tacrolimus for systemic lupus erythematosus treatment: results from a real-world CSTAR cohort study. Lupus Sci Med 2022; 9:9/1/e000617. [PMID: 34980680 PMCID: PMC8724817 DOI: 10.1136/lupus-2021-000617] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The effectiveness and safety of sirolimus for SLE treatment have been shown in some uncontrolled studies. However, a comparison of sirolimus with other classic immunosuppressants has not been reported. We conducted the study to compare the effectiveness and safety of sirolimus versus tacrolimus for SLE treatment. METHODS A real-world cohort study was conducted. Patients with clinically active SLE who were prescribed sirolimus or tacrolimus were enrolled. Propensity score matching was used to ensure equivalent disease conditions and background medications. SLE disease activity indices, serological parameters, steroid doses, modification of other immunosuppressants, renal effectiveness and adverse events were compared between the two groups at 3-month, 6-month, 9-month and 12-month follow-up visits. RESULTS Data from 52 patients in each of the sirolimus and tacrolimus groups were analysed. Indices regarding the effectiveness of sirolimus, including Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores, physician's global assessment (PhGA) scores, and proportion of patients with SLEDAI-2K reduction of ≥4 and PhGA increase of <0.3, were equivalent to those of tacrolimus at all follow-up timepoints (all p≥0.05). Greater improvements in complement levels were observed in the sirolimus group at 3 and 6 months. Higher percentages of patients with prednisone doses ≤7.5 mg/day were observed in the sirolimus group at all timepoints. Seventeen adverse events in the sirolimus group were recorded. None was severe or led to drug discontinuation. CONCLUSIONS Overall, sirolimus was as effective as tacrolimus in the treatment of SLE. Sirolimus had better effects on serological improvement and glucocorticoid tapering. Sirolimus was well tolerated in patients with SLE.
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Affiliation(s)
- Nan Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Hongfeng Zhang
- Department of Rheumatology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaofeng Li
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Yongfei Fang
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Hongbin Li
- Department of Rheumatology, The Affiliated Hospital of Inner Mongolia Medical College, Hohhot, China
| | - Pingting Yang
- Department of Rheumatology and Immunology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Hui Luo
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liying Peng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chanyuan Wu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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29
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Perea-Seoane L, Agapito-Vera E, Gamboa-Cardenas RV, Guzmán-Sánchez G, Pimentel-Quiroz VR, Reategui-Sokolova C, Medina M, Elera-Fitzcarrald C, Noriega E, Rodriguez-Bellido Z, Pastor-Asurza C, Perich-Campos R, Alarcón GS, Ugarte-Gil MF. Relationship between care model and disease activity states and health-related quality of life in systemic lupus erythematosus patients. Lupus 2021; 31:110-115. [PMID: 34969318 DOI: 10.1177/09612033211063798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess whether the care model (comprehensive vs regular) has any impact on the clinical outcomes of systemic lupus erythematosus patients. METHODS Between August 2019 and January 2020, we evaluated SLE patients being cared for at two Peruvian hospitals to define the impact of care model on disease activity state and health-related quality of life (HRQoL). Disease activity was ascertained with the SLEDAI-2K and the Physician Global Assessment (PGA) which allows to define Lupus Low Disease Activity State (LLDAS) and Remission. HRQoL was measured with the LupusQoL. The association between care model and disease activity (Remission and LLDAS) state was examined using a binary logistic regression model. The association with HRQoL was examined with a linear regression model. All multivariable analyses were adjusted for possible confounders. RESULTS 266 SLE patients were included, 227 from the comprehensive care model and 39 from the regular care model. The regular care model was associated with a lower probability of achieving remission (OR 0.381; CI: 95% 0.163-0.887) and LLDAS (OR 0.363; CI: 95% 0.157-0.835). Regular care was associated with a better HRQoL in two domains (pain and emotional health). We found no association between the care model and the other HRQoL domains. CONCLUSION A comprehensive care model was associated with the probability of achieving remission and LLDAS but had no apparent impact on the patients' HRQoL.
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Affiliation(s)
| | | | - Rocío V Gamboa-Cardenas
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,Rheumatology Department, 280155Hospital Guillermo Almenara Irigoyen, La Victoria, Peru
| | | | - Victor Román Pimentel-Quiroz
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,Rheumatology Department, 280155Hospital Guillermo Almenara Irigoyen, La Victoria, Peru
| | - Cristina Reategui-Sokolova
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,Unidad de Investigación para La Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Mariela Medina
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru
| | - Claudia Elera-Fitzcarrald
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,Rheumatology Department, 280155Hospital Guillermo Almenara Irigoyen, La Victoria, Peru
| | - Erika Noriega
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru
| | - Zoila Rodriguez-Bellido
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Cesar Pastor-Asurza
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Risto Perich-Campos
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Graciela S Alarcón
- School of Medicine, the University of Alabama at Birmingham, Birmingham, AL USA.,School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Manuel F Ugarte-Gil
- School of Medicine, 187071Universidad Científica del Sur, Lima, Peru.,Rheumatology Department, 280155Hospital Guillermo Almenara Irigoyen, La Victoria, Peru
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30
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Smith EMD, Tharmaratnam K, Al-Abadi E, Armon K, Bailey K, Brennan M, Ciurtin C, Gardner-Medwin J, Haslam KE, Hawley D, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Hedrich CM, Jorgensen A, Beresford MW. Attainment of Low Disease Activity and Remission Targets reduces the risk of severe flare and new damage in Childhood Lupus. Rheumatology (Oxford) 2021; 61:3378-3389. [PMID: 34894234 PMCID: PMC9348762 DOI: 10.1093/rheumatology/keab915] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). Methods Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice–Williams–Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. Results LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). Conclusions This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kukatharmini Tharmaratnam
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | | | - Kirsty E Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Rheumatology Department, Aintree University Hospital, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - Philip Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital & Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Andrea Jorgensen
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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31
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Assunção H, Jesus D, Larosa M, Henriques C, Matos A, Le Guern V, Rubiño F, da Silva JAP, Rua-Figueroa I, Costedoat-Chalumeau N, Doria A, Inês LS. Definition of Low Disease Activity State based on the SLE-DAS: Derivation and validation in a multicentre real-life cohort. Rheumatology (Oxford) 2021; 61:3309-3316. [PMID: 34864894 DOI: 10.1093/rheumatology/keab895] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/23/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To derive and validate a definition of low disease activity (LDA) for systemic lupus erythematosus (SLE) based on the SLE Disease Activity Score (SLE-DAS), in a real-life multicentre cohort of SLE patients. METHODS Derivation was conducted using data from a monocentric cohort of SLE (Portugal), and validation was performed in a multicentre cohort (Italy, France, and Spain). The Lupus Low Disease Activity State (LLDAS) was used as comparator. We applied receiver operating characteristics (ROC) curve analysis against the LLDAS to determine the cut-off of SLE-DAS for LDA using bootstrap methodology. In a second step, we tested a definition of SLE-DAS LDA that included: (i) the statistically derived SLE-DAS upper threshold for LDA, and (ii) prednisone dose ≤7.5 mg/day. In the multicentre validation cohort, we assessed the classification performance of this SLE-DAS LDA definition. RESULTS We included 774 patients, 300 in the derivation and 474 in the validation cohorts, respectively. In the derivation cohort, the optimal cut-off to identify patients in LLDAS was SLE-DAS ≤2.48, presenting an area under the curve (AUC) of 0.965 (95%CI 0.935-0.994). When applied to the multicentre validation cohort, the SLE-DAS LDA definition showed a sensitivity of 97.1% and a specificity of 97.7% for LLDAS and an almost perfect agreement (Cohen's Kappa =0.933; p< 0.001). McNemar's test found no significant differences between the two definitions (p= 0.092). CONCLUSION The SLE-DAS LDA is a validated, accurate, and easy-to-use definition for classifying SLE patients in LDA state.
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Affiliation(s)
- Helena Assunção
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra
| | - Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria. Leiria, Portugal.,Faculty of Health Sciences, University of Beira Interior. Covilhã, Portugal
| | | | - Carla Henriques
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,Centre for Mathematics, University of Coimbra, Coimbra, Portugal
| | - Ana Matos
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,CISeD-Research Centre in Digital Services, Polytechnic of Viseu, Portugal
| | - Véronique Le Guern
- APHP, Internal Medicine Department, Cochin Hospital, Paris, France; Université de Paris, Paris, France
| | - Francisco Rubiño
- Rheumatology Department, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Spain
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Iñigo Rua-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Spain
| | | | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | - Luís S Inês
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Faculty of Health Sciences, University of Beira Interior. Covilhã, Portugal
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32
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van Vollenhoven RF, Bertsias G, Doria A, Isenberg D, Morand E, Petri MA, Pons-Estel BA, Rahman A, Ugarte-Gil MF, Voskuyl A, Arnaud L, Bruce IN, Cervera R, Costedoat-Chalumeau N, Gordon C, Houssiau FA, Mosca M, Schneider M, Ward MM, Alarcon G, Aringer M, Askenase A, Bae SC, Bootsma H, Boumpas DT, Brunner H, Clarke AE, Coney C, Czirják L, Dörner T, Faria R, Fischer R, Fritsch-Stork R, Inanc M, Jacobsen S, Jayne D, Kuhn A, van Leeuw B, Limper M, Mariette X, Navarra S, Nikpour M, Olesinska MH, Pons-Estel G, Romero-Diaz J, Rubio B, Schoenfeld Y, Bonfá E, Smolen J, Teng YKO, Tincani A, Tsang-A-Sjoe M, Vasconcelos C, Voss A, Werth VP, Zakharhova E, Aranow C. 2021 DORIS definition of remission in SLE: final recommendations from an international task force. Lupus Sci Med 2021; 8:8/1/e000538. [PMID: 34819388 PMCID: PMC8614136 DOI: 10.1136/lupus-2021-000538] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/04/2021] [Indexed: 11/12/2022]
Abstract
Objective To achieve consensus on a definition of remission in SLE (DORIS). Background Remission is the stated goal for both patient and caregiver, but consensus on a definition of remission has been lacking. Previously, an international task force consisting of patient representatives and medical specialists published a framework for such a definition, without reaching a final recommendation. Methods Several systematic literature reviews were performed and specific research questions examined in suitably chosen data sets. The findings were discussed, reformulated as recommendations and voted on. Results Based on data from the literature and several SLE-specific data sets, a set of recommendations was endorsed. Ultimately, the DORIS Task Force recommended a single definition of remission in SLE, based on clinical systemic lupus erythematosus disease activitiy index (SLEDAI)=0, Evaluator’s Global Assessment <0.5 (0–3), prednisolone 5 mg/day or less, and stable antimalarials, immunosuppressives, and biologics. Conclusion The 2021 DORIS definition of remission in SLE is recommended for use in clinical care, education, and research including clinical trials and observational studies.
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Affiliation(s)
- Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
| | - Eric Morand
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Michelle A Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Anisur Rahman
- Medicine (Rheumatology), University College London, London, UK
| | | | | | - Laurent Arnaud
- Department of Rheumatology, Strasbourg University Hospitals, Strasbourg, France.,Strasbourg Federation of Translational Medicine (FMTS), University of Strasbourg, Strasbourg, France
| | - Ian N Bruce
- The University of Manchester, Manchester, UK
| | | | | | - Caroline Gordon
- Rheumatology Research Group, University of Birmingham, Birmingham, UK
| | - Frédéric A Houssiau
- Pole of Rheumatic Pathologies, Catholic University of Louvain, Institute for Experimental and Clinical Research, Brussels, Belgium.,Rheumatology Department, Saint-Luc University Clinics, Brussels, Belgium
| | | | - Matthias Schneider
- Policlinic for Rheumatology & Hiller Research Centre for Rheumatology, Heinrich-Heine-University, Düsseldorf, Germany
| | | | | | | | - Anka Askenase
- Columbia University Medical Center, New York, New York, USA
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University Seoul Hospital, Seoul, Korea (the Republic of)
| | | | | | - Hermine Brunner
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Cindy Coney
- Lupus Foundation of America, Washington, District of Columbia, USA
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pecs, Pecs, Hungary
| | - Thomas Dörner
- Charite University Hospitals Berlin, Berlin, Germany
| | - Raquel Faria
- Clinical Immunology Unit, Porto Hospital and University Center, Porto, Portugal
| | - Rebecca Fischer
- Rheumatology, Heinrich-Heine-University, Duesseldorf, Germany
| | | | - Murat Inanc
- Internal Medicine Rheumatology, University of Istanbul, Istanbul, Turkey
| | - Søren Jacobsen
- Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Jayne
- Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | - Maarten Limper
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - Xavier Mariette
- Public Assistance, Paris Hospitals, Paris Saclay University, Le Kremlin-Bicetre, France
| | - Sandra Navarra
- Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Mandana Nikpour
- Medicine and Rheumatology, University of Melbourne, Fitzroy, Victoria, Australia
| | | | - Guillermo Pons-Estel
- Regional Center for Autoimmune and Rheumatic Diseases (GO-CREAR), Rosario, Argentina
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | | | - Yehuda Schoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Eloisa Bonfá
- Rheumatology, University of Sao Paulo Faculty of Medicine, Sao Paulo, Brazil
| | | | - Y K Onno Teng
- Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Michel Tsang-A-Sjoe
- Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Anne Voss
- Department of Rheumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Victoria P Werth
- Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elena Zakharhova
- Rheumatology, A I Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russian Federation Faculty of Dentistry, Moskva, Russian Federation
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, The Feinstein Institute for Medical Research, Manhasset, New York, USA
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33
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Ringold S, Consolaro A, Ardoin SP. Outcome Measures in Pediatric Rheumatic Disease. Rheum Dis Clin North Am 2021; 47:655-668. [PMID: 34635297 DOI: 10.1016/j.rdc.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Reliable and responsive outcome measures that accurately detect changes in disease state, activity, and damage are crucial to conducting observational and interventional trials that can directly transform care for children with rheumatic disease. A combination of consensus-based and direct measurement approaches has led to the development of several validated, composite outcome measures in juvenile idiopathic arthritis, juvenile dermatomyositis, childhood-onset systemic lupus erythematosus, and pediatric vasculitis. This review outlines clinician-reported, disease-specific outcome measures developed for these conditions.
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Affiliation(s)
- Sarah Ringold
- Seattle Children's, 4800 Sand Point Way Northeast, Seattle, WA 98115, USA.
| | - Alessandro Consolaro
- Rheumatology Unit, Istituto Giannina Gaslini, University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Stacy P Ardoin
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
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Ugarte-Gil MF, Mendoza-Pinto C, Reátegui-Sokolova C, Pons-Estel GJ, van Vollenhoven RF, Bertsias G, Alarcon GS, Pons-Estel BA. Achieving remission or low disease activity is associated with better outcomes in patients with systemic lupus erythematosus: a systematic literature review. Lupus Sci Med 2021; 8:e000542. [PMID: 34548375 PMCID: PMC8458331 DOI: 10.1136/lupus-2021-000542] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Remission and low disease activity (LDA) have been proposed as the treatment goals for patients with systemic lupus erythematosus (SLE). Several definitions for each have been proposed in the literature. OBJECTIVE To assess the impact of remission/LDA according to various definitions on relevant outcomes in patients with SLE. METHODS This systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed (1946-week 2, April 2021), Cochrane library (1985-week 2, week 2, April 2021) and EMBASE (1974-week 2, April 2021). We included longitudinal and cross-sectional studies in patients with SLE reporting the impact of remission and LDA (regardless their definition) on mortality, damage accrual, flares, health-related quality of life and other outcomes (cardiovascular risk, hospitalisation and direct costs). The quality of evidence was evaluated using the Newcastle-Ottawa Scale. RESULTS We identified 7497 articles; of them, 31 studies met the inclusion criteria and were evaluated. Some articles reported a positive association with survival, although this was not confirmed in all of them. Organ damage accrual was the most frequently reported outcome, and remission and LDA were reported as protective of this outcome (risk measures varying from 0.04 to 0.95 depending on the definition). Similarly, both states were associated with a lower probability of SLE flares, hospitalisations and a better health-related quality of life, in particular the physical domain. CONCLUSION Remission and LDA are associated with improvement in multiple outcomes in patients with SLE, thus reinforcing their relevance in clinical practice. PROSPERO REGISTRATION NUMBER CRD42020162724.
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Affiliation(s)
- Manuel Francisco Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, Mexican Institute of Social Security, Puebla, Puebla, Mexico
- Medicine School, Benemerita Universidad Autonoma de Puebla, Puebla, Puebla, Mexico
| | - Cristina Reátegui-Sokolova
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
- Universidad San Ignacio de Loyola, Lima, Peru
| | - Guillermo J Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Santa Fe, Argentina
| | - Ronald F van Vollenhoven
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, Netherlands
| | | | - Graciela S Alarcon
- School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Santa Fe, Argentina
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Jesus D, Larosa M, Henriques C, Matos A, Zen M, Tomé P, Alves V, Costa N, Le Guern V, Iaccarino L, Costedoat-Chalumeau N, Doria A, Inês LS. Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) enables accurate and user-friendly definitions of clinical remission and categories of disease activity. Ann Rheum Dis 2021; 80:1568-1574. [PMID: 34407927 DOI: 10.1136/annrheumdis-2021-220363] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/24/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES There is an unmet need for accurate and user-friendly definitions of systemic lupus erythematosus (SLE) disease activity and remission. We aimed to derive and validate the SLE Disease Activity Score (SLE-DAS) definitions for disease activity categories and clinical remission state. METHODS Derivation was conducted at Padova Lupus Clinic (Italy). Validation was prospectively performed at Cochin Lupus Clinic (France) and by post hoc analysis of BLISS-76 trial. At each clinic, an expert classified patients in three categories: remission, mild or moderate/severe activity. The SLE-DAS cut-offs were derived using the receiver operating characteristic curve analysis in Padova cohort; its performance was assessed against expert classification in Cochin cohort and British Isles Lupus Assessment Group (BILAG) index in BLISS-76. Gold standard for clinical remission state was the fulfilment of Definition Of Remission In SLE. A Boolean and an index-based definitions of remission were sustained by chi-square automatic interaction detection algorithm. An SLE-DAS online calculator was developed and tested. RESULTS We included 1190 patients with SLE: 221 in the derivation cohort and 969 in the validation cohorts (150 from Cochin; 819 from BLISS-76). Derived cut-offs were: remission, SLE-DAS ≤2.08; mild activity, 2.08<SLE-DAS≤7.64; moderate/severe activity, SLE-DAS >7.64. Regarding validation in Cochin cohort, sensitivity and specificity are above 90%, 82% and 95% for remission, mild and moderate/severe activity, respectively. The SLE-DAS Boolean-based and index-based remission showed sensitivity of 100% and specificity above 97%. CONCLUSION The SLE-DAS is an accurate and easy-to-use tool for defining SLE clinical remission state and disease activity categories, validated against expert assessment and BILAG.
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Affiliation(s)
- Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Carla Henriques
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,Centre for Mathematics, University of Coimbra, Coimbra, Portugal
| | - Ana Matos
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,Research Centre in Digital Services, CISeD, Viseu, Portugal
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Paulo Tomé
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal
| | - Valter Alves
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,Research Centre in Digital Services, CISeD, Viseu, Portugal
| | - Nuno Costa
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal
| | | | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | | | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Luís Sousa Inês
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal .,CHUC Lupus Clinic, Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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36
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Irino K, Arinobu Y, Ayano M, Kawano S, Kimoto Y, Mitoma H, Akahoshi M, Akashi K, Horiuchi T, Niiro H. Predictive factors of fetal and maternal pregnancy outcomes in Japanese patients with systemic lupus erythematosus. Lupus 2021; 30:1637-1643. [PMID: 34266321 DOI: 10.1177/09612033211031989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The number of pregnant and delivery cases in systemic lupus erythematosus (SLE) patients are increasing due to the advances in therapies. However, there are many problems such as the exacerbation of SLE during pregnancy and the risk of fetal complications. We investigated the impact of both pregnancy on lupus and lupus on pregnancy in Japanese patients. METHODS We retrospectively analyzed 64 pregnancies in 39 cases of lupus patients at Kyushu University Hospital, Japan, from October 2002 to July 2018 and then assessed the clinical profiles and maternal and fetal outcomes. RESULTS In terms of the impact of pregnancy on SLE, 29.7% of patients had lupus flare during pregnancy. Multivariate analysis showed that flare rates were significantly higher in patients who discontinued the immunosuppressants when pregnancy was detected or before pregnancy. Pregnancy results were 25.0% for preterm birth, 39.1% for low birth weight infants, and 31.3% for small-for-gestational-age infants. Regarding the effect of SLE on fetal death, the rates of stillbirth were significantly higher in cases whose C3 value at 12 weeks of gestation was lower than before conception. Preterm birth was associated with disease duration and lupus flare during pregnancy. CONCLUSIONS Discontinuation of immunosuppressive drugs was a predictive factor for lupus flare during pregnancy. Further, the decrease of C3 levels at 12 weeks of gestation from baseline was a predictive factor for fetal loss. It is essential for lupus pregnant patients to prevent flares, even with the use of immunosuppressive medications.
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Affiliation(s)
- Kensuke Irino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, 73912Kyushu University Beppu Hospital, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
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37
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Larosa M, Costedoat-Chalumeau N, Guettrot-Imbert G, Le Guern V, Morel N, Jesus D, Iaccarino L, Inês L, Doria A. SLE-DAS in the First Trimester of Gestation Predicts Maternal Lupus Flares Later in Pregnancy. Front Pharmacol 2021; 12:660123. [PMID: 33935783 PMCID: PMC8085518 DOI: 10.3389/fphar.2021.660123] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction: Systemic Lupus Erythematosus (SLE) mainly occurs during childbearing age. Remission or low disease activity state (LDAS) before conception are recommended by experts to achieve a favourable lupus pregnancy outcome but little is known on the best way to evaluate remission or activity status during pregnancy. Objectives: We tested SLE-disease activity score (SLE-DAS) in the first trimester as predictor of maternal flares and obstetrical complications in 2nd and 3rd trimester in a cohort of SLE pregnant women. Patients and Methods: Inclusion criteria were: 1) women ≥ 18 years; 2) affected with SLE (SLICC 2012); 3) enrolled in two referral centers (Italy and France) 4) with an ongoing singleton pregnancy at 12 weeks (only one pregnancy per patient). Disease activity was assessed at first trimester of pregnancy, using SLE-pregnancy disease activity index (SLEPDAI) and retrospectively applying SLE-DAS. Maternal lupus flares at 2nd and 3rd trimester were defined by the SELENA-SLEDAI Flare Index (SFI). Adverse pregnancy outcome (APO) included: fetal and neonatal death, placental insufficiency with premature delivery <37 weeks, and small for gestational age (SGA) (≤3rd percentile). Results: We included 158 pregnant patients affected with SLE. At first trimester the median SLEPDAI (IQR) was 2 (0-4) and the median SLE-DAS (IQR) 1.32 (0.37-2.08). At least one flare occurred in 25 (15.8%) women during the 2nd and 3rd trimester. APO occurred in 19 (12.0%) patients. A significant correlation between SLE-DAS and SLEPDAI was found in this cohort (Spearman's ρ = 0.97, Figure 1). At multivariate analysis, both SLE-DAS and SLEPDAI predicted maternal flares (adjOR = 1.2; 95% CI = 1.0-1.3, p = 0.02; adjOR 1.3, 95% CI = 1.1-1.6 per unit increase, p = 0.01, respectively). SLE-DAS and SLEPDAI were associated with APO at univariate analysis (p = 0.02). Conclusions: SLE-DAS was highly correlated with SLEPDAI and its use in the first trimester predicted maternal flares in the 2nd and 3rd trimester, making SLE-DAS a reliable instrument to measure SLE activity during pregnancy.
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Affiliation(s)
- Maddalena Larosa
- Rheumatology Unit, Department of Medicine, DIMED, University of Padova, Padova, Italy.,Internal Medicine Department, Hôpital Cochin, Paris, France.,Centre de Référence Maladies Auto-immunes et Systémiques Rares, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Hôpital Cochin, Paris, France.,Centre de Référence Maladies Auto-immunes et Systémiques Rares, Paris, France.,University of Paris, Paris, France
| | - Gaëlle Guettrot-Imbert
- Internal Medicine Department, Hôpital Cochin, Paris, France.,Centre de Référence Maladies Auto-immunes et Systémiques Rares, Paris, France
| | - Veronique Le Guern
- Internal Medicine Department, Hôpital Cochin, Paris, France.,Centre de Référence Maladies Auto-immunes et Systémiques Rares, Paris, France
| | - Nathalie Morel
- Internal Medicine Department, Hôpital Cochin, Paris, France.,Centre de Référence Maladies Auto-immunes et Systémiques Rares, Paris, France
| | - Diogo Jesus
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Luís Inês
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, DIMED, University of Padova, Padova, Italy
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Hill DD, Eudy AM, Egger PJ, Fu Q, Petri MA. Impact of systemic lupus erythematosus disease activity, hydroxychloroquine and NSAID on the risk of subsequent organ system damage and death: analysis in a single US medical centre. Lupus Sci Med 2021; 8:8/1/e000446. [PMID: 33832976 PMCID: PMC8039259 DOI: 10.1136/lupus-2020-000446] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/26/2021] [Accepted: 03/11/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To assess the impact of mild-moderate systemic lupus erythematosus (SLE) disease activity during a 12-month period on the risk of death or subsequent organ system damage. METHODS 1168 patients with ≥24 months of follow-up from the Hopkins Lupus Cohort were included. Disease activity in a 12-month observation period was calculated using adjusted mean Safety of Estrogens in Lupus Erythematosus National Assessment (SELENA) version of the SLE Disease Activity Index (SLEDAI), defined as the area under the curve divided by the time interval. Damage accrual in the follow-up period was defined as change in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score ≥1 among patients without prior damage. Patients visited the clinic quarterly and had SELENA-SLEDAI and SDI assessed at every visit. RESULTS During follow-up (median 7 years), 39% of patients accrued new damage in any organ system (7% cardiovascular and 3% renal) and 8% died. In adjusted models, an increased SELENA-SLEDAI score increased the risk of death (HR=1.22, 95% CI 1.13 to 1.32, p<0.001), renal damage (HR=1.24, 95% CI 1.08 to 1.42, p=0.003) and cardiovascular damage (HR=1.17, 95% CI 1.07 to 1.29, p<0.001). Hydroxychloroquine use reduced the risk of death (HR=0.46, 95% CI 0.29 to 0.72, p<0.05) and renal damage (HR=0.30, 95% CI 0.13 to 0.68, p<0.05). Non-steroidal anti-inflammatory drug use increased the risk of cardiovascular damage (HR=1.66, 95% CI 1.04 to 2.63, p<0.05). Without prior damage, an increased adjusted mean SELENA-SLEDAI score increased the risk of overall damage accrual (HR=1.09, 95% CI 1.04 to 1.15, p<0.001). CONCLUSIONS Each one-unit increase in adjusted mean SELENA-SLEDAI during a 12-month observation period was associated with an increased risk of death and developing cardiovascular and renal damage.
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Affiliation(s)
- Deanna D Hill
- Real World Evidence, Epidemiology, GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Amanda M Eudy
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Peter J Egger
- Real World Evidence, Epidemiology, GlaxoSmithKline, Uxbridge, UK
| | - Qinggong Fu
- Real World Evidence, Epidemiology, GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Michelle A Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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39
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Nikfar M, Malek Mahdavi A, Khabbazi A, Hajialilo M. Long-term remission in patients with systemic lupus erythematosus. Int J Clin Pract 2021; 75:e13909. [PMID: 33277751 DOI: 10.1111/ijcp.13909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/19/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Remission has been introduced as a desirable outcome and the primary target of treatment in systemic lupus erythematosus (SLE). The purpose of this study was to identify the number of patients in remission and the long-term outcome of the disease and their predictors. METHOD Of the 379 patients in our SLE Database, a total of 193 patients fulfilled the inclusion criteria. Remission was definition according to the definitions of remission in SLE. Three levels of remission were defined, including remission on-treatment, remission off-treatment and complete remission. In addition, we have defined a sustained remission for each level of remission in which the remission should last at least 5 years. RESULTS During a median follow-up of 96 months, remission on-treatment and off-treatment, and complete remission were obtained in 49.2%, 38.9% and 19.2% of patients, respectively. Predictors of remission on-treatment in multivariate regression analysis were adherence to therapy and remission induction during 6 months after treatment. Predictors of remission off-treatment were age ≥40 at the time of analysis and remission induction during 6 months after treatment. Poor outcome (SLE Damage Index ≥1) was observed in 28% of the patients. Age at disease onset <30, kidney and nervous system involvement and SLEDAI-2K ≥ 11 at the cohort entry were the risk factors of poor outcome in multivariate analysis. However, sustained remission on-treatment had a negative association with poor outcome. CONCLUSION Treatment with glucocorticoids, antimalarials, immunosuppressants and biologics in sequential or in combination may cause durable remission. Patients with durable remission have significantly lower organ damage.
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Affiliation(s)
- Mozhdeh Nikfar
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aida Malek Mahdavi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrzad Hajialilo
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Gómez-Puerta JA, Pons-Estel GJ, Quintana R, Nieto R, Serrano Morales RM, Harvey GB, Wojdyla D, Scolnik M, Funes Soaje C, Alba Moreyra P, Novatti E, Arizpe F, Berbotto GA, González Lucero L, Porta S, Pérez N, Rodriguez AM, Appenzeller S, de Oliveira E Silva Montadon AC, Monticielo OA, Cavalcanti FS, Machado Ribeiro F, Borba EF, Torres Dos Reis-Neto E, Neira O, Chahuán JM, Mimica M, Aroca Martínez G, Tobón GJ, Vásquez G, Quintana-Lopez G, Moreno Alvarez MJ, Saavedra MÁ, Cristobal MP, Fragoso-Loyo H, Amezcua-Guerra LM, González-Bello YC, Abud-Mendoza C, Esquivel-Valerio JA, Duarte M, Acosta Colman I, Mora-Trujillo C, Reátegui-Sokolova C, Calvo Quiroz AA, Muñoz-Louis R, Cairoli E, Rosas I, Rebella M, Cardiel MH, García de la Torre I, Catoggio LJ, Alarcón GS, Pons-Estel BA. A longitudinal multiethnic study of biomarkers in systemic lupus erythematosus: Launching the GLADEL 2.0 Study Group. Lupus 2021; 30:961203320988586. [PMID: 33509067 DOI: 10.1177/0961203320988586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: After more than 20 years of sustained work, the Latin American Group for the Study of Lupus (GLADEL) has made a significant number of contributions to the field of lupus, not only in the differential role that race/ethnicity plays in its course and outcome but also in several other studies including the beneficial effects of using antimalarials in lupus patients and the development of consensus guidelines for the treatment of lupus in our region. Methods: A new generation of "Lupus Investigators" in more than 40 centers throughout Latin America has been constituted in order to continue the legacy of the investigators of the original cohort and to launch a novel study of serum and urinary biomarkers in patients with systemic lupus erythematosus. Results: So far, we have recruited 807 patients and 631 controls from 42 Latin-American centers including 339 patients with SLE without renal involvement, 202 patients with SLE with prevalent but inactive renal disease, 176 patients with prevalent and active renal disease and 90 patients with incident lupus nephritis. Conclusions: The different methodological aspects of the GLADEL 2.0 cohort are discussed in this manuscript, including the challenges and difficulties of conducting such an ambitious project.
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Affiliation(s)
| | | | - Rosana Quintana
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Romina Nieto
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | | | - Guillermina B Harvey
- Escuela de Estadística, Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Marina Scolnik
- Rheumatology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carmen Funes Soaje
- Servicio de Reumatología, Hospital Italiano de Córdoba, Córdoba, Argentina
| | - Paula Alba Moreyra
- Hospital Córdoba, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Elisa Novatti
- Servicio de Reumatología, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Fernando Arizpe
- Servicio de Reumatología, HIGA San Martin de La Plata, Argentina
| | - Guillermo A Berbotto
- Servicio de Reumatología, Hospital Escuela "Eva Perón", Granadero Baigorria, Argentina
| | | | - Sabrina Porta
- Rheumatology Department, Hospital "José María Ramos Mejía", Buenos Aires, Argentina
| | - Nicolás Pérez
- Departamento de Inmunología, Instituto de Investigaciones Médicas "Alfredo Lanari", Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Anabella M Rodriguez
- Sección de Reumatología e Inmunología, Centro De Educación Médica e Investigaciones Clínicas, "Norberto Quirno" (CEMIC), Buenos Aires, Argentina
| | | | | | - Odirlei Andre Monticielo
- Rheumatology Division, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernando S Cavalcanti
- Serviço de Reumatologia, Departamento de Medicina Clínica, Centro de Ciências Médicas, Hospital das Clínicas, Universidade Federal de Pernambuco, Pernambuco, Brazil
| | - Francinne Machado Ribeiro
- Rheumatology Division, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eduardo F Borba
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Oscar Neira
- Sección de Reumatología, Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - José Miguel Chahuán
- Departamento de Inmunología Clínica y Reumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Milena Mimica
- Centro de Biología Celular y Biomedicina (CEBICEM), Facultad de Medicina y Ciencia, Universidad San Sebastián, Chile
| | - Gustavo Aroca Martínez
- Universidad Simón Bolívar, Barranquilla, Colombia
- Clínica de la Costa, Barranquilla, Colombia
| | - Gabriel J Tobón
- Unidad de Reumatología, Fundación Valle del Lili, Facultad de Medicina, Universidad ICESI, Cali, Colombia
| | - Gloria Vásquez
- Sección de Reumatología, Departamento de Medicina Interna/Grupo de Inmunología Celular e Inmunogenética, Facultad de Medicina, Universidad de Antioquía, Medellín, Colombia
| | - Gerardo Quintana-Lopez
- REUMAVANCE Group, Rheumatology Section, Department of Internal Medicine, Fundación Santa Fe de Bogotá, University Hospital, Bogotá, Colombia
- Department of Internal Medicine, School of Medicine, Universidad de Los Andes, Bogotá, Colombia
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Mario J Moreno Alvarez
- Servicio Reumatología, Hospital "Luis Vernaza", Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador
| | - Miguel Ángel Saavedra
- Hospital de Especialidades "Dr. Antonio Fraga Mouret", Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Mario Pérez Cristobal
- Departamento de Reumatología, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, del Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Hilda Fragoso-Loyo
- Departamento de Inmunología y Reumatología, Instituto Nacional Ciencias Medicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | - Luis M Amezcua-Guerra
- Departamento de Inmunología/Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Yelitza C González-Bello
- Centro de Estudios de Investigación Básica y Clínica, S.C., Departamento de Inmunología, Guadalajara, México
| | - Carlos Abud-Mendoza
- Unidad Regional de Reumatología, Hospital Central "Dr. Ignacio Morones Prieto", y Facultad de Medicina, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - Jorge A Esquivel-Valerio
- Servicio de Reumatología, Hospital Universitario "Dr, José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
| | - Margarita Duarte
- Primera Cátedra de Clínica Médica, Facultad de Ciencias Medicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Isabel Acosta Colman
- Departamento de Reumatología, Facultad de Ciencias Medicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Claudia Mora-Trujillo
- Servicio de Reumatología, Departamento de Especialidades Médicas, Hospital Nacional "Edgardo Rebagliati Martins", Lima, Perú
| | | | | | | | - Ernesto Cairoli
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Evangélico, Montevideo, Uruguay
- Unidad de Enfermedades Autoinmunes Sistémicas, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Iliana Rosas
- Instituto Nacional de Reumatología/Hospital Pasteur, Montevideo, Uruguay
| | - Martín Rebella
- Unidad de Enfermedades Autoinmunes de Médica Uruguaya Corporación de Asistencia Médica (MUCAM). Clínica Médica, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, México
| | - Ignacio García de la Torre
- Departamento de Inmunología y Reumatología, Hospital General de Occidente de la S.S. y Universidad de Guadalajara, Zapopan, Jalisco, México
| | - Luis J Catoggio
- Rheumatology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Graciela S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, USA
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano, Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Piga M, Floris A, Sebastiani GD, Prevete I, Iannone F, Coladonato L, Govoni M, Bortoluzzi A, Mosca M, Tani C, Doria A, Iaccarino L, Franceschini F, Fredi M, Conti F, Spinelli FR, Galeazzi M, Bellisai F, Zanetti A, Carrara G, Scirè CA, Mathieu A. Risk factors of damage in early diagnosed systemic lupus erythematosus: results of the Italian multicentre Early Lupus Project inception cohort. Rheumatology (Oxford) 2021; 59:2272-2281. [PMID: 31840179 DOI: 10.1093/rheumatology/kez584] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/25/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate risk factors for damage development in a prospective inception cohort of early diagnosed SLE patients. METHODS The Early Lupus Project recruited an inception cohort of patients within 12 months of SLE classification (1997 ACR criteria). At enrolment and every 6 months thereafter, the SLICC/ACR Damage Index was recorded. The contribution of baseline and time-varying covariates to the development of damage, defined as any SLICC/ACR Damage Index increase from 0 to ≥1, was assessed using univariate analysis. Forward-backward Cox regression models were fitted with covariates with P < 0.05 to identify factors independently associated with the risk of damage development. RESULTS Overall, 230 patients with a mean (s.d.) age of 36.5 (14.4) years were eligible for this study; the mean number of visits per patient was 5.3 (2.7). There were 51 (22.2%) patients with SLICC/ACR Damage Index ≥1 after 12 months, 59 (25.6%) after 24 months and 67 (29.1%) after 36 months. Dyslipidaemia [P = 0.001; hazard ratio (HR) 2.9; 95% CI 1.5, 5.6], older age (P = 0.001; HR 3.0; 95% CI 1.6, 5.5), number of organs/systems involved (P = 0.002; HR 1.4; 95% CI 1.1, 1.8) and cardiorespiratory involvement (P = 0.041; HR 1.9; 95% CI 1.0, 3.7) were independently associated with an increased risk of developing damage. Risk profiles for damage development differed for glucocorticoid-related and -unrelated damage. HCQ use (P = 0.005; HR 0.4; 95% CI 0.2, 0.8) reduced the risk of glucocorticoid-unrelated damage. CONCLUSION We identified risk factors of damage development, but little effect of glucocorticoids, in this early SLE cohort. Addressing modifiable risk factors from the time of SLE diagnosis might improve patient outcomes.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, University of Cagliari and AOU University Clinic, Cagliari
| | - Alberto Floris
- Rheumatology Unit, University of Cagliari and AOU University Clinic, Cagliari
| | | | - Imma Prevete
- UOC di Reumatologia, Azienda Ospedaliera San Camillo-Forlanini, Rome
| | - Florenzo Iannone
- Dipartimento dell'Emergenza e dei Trapianto di Organi - Sezione di Reumatologia, Università di Bari, Bari
| | - Laura Coladonato
- Dipartimento dell'Emergenza e dei Trapianto di Organi - Sezione di Reumatologia, Università di Bari, Bari
| | - Marcello Govoni
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara
| | - Alessandra Bortoluzzi
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara
| | - Marta Mosca
- UOC di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa
| | - Chiara Tani
- UOC di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova
| | - Franco Franceschini
- UOC di Reumatologia e Immunologia Clinica, Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, ASST Spedali Civili, Brescia, Italy
| | - Micaela Fredi
- UOC di Reumatologia e Immunologia Clinica, Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, ASST Spedali Civili, Brescia, Italy
| | - Fabrizio Conti
- Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Roma
| | - Francesca Romana Spinelli
- Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Roma
| | - Mauro Galeazzi
- UOC di Reumatologia, Azienda Ospedaliera Universitaria Senese, Siena
| | | | - Anna Zanetti
- Società Italiana di Reumatologia, Unità Epidemiologica, Milano.,Divisione di Biostatistica, Epidemiologia e Salute Pubblica, Dipartimento di Statistica e Metodi Quantitativi, Università degli Studi di Milano-Bicocca, Milano, Italy
| | - Greta Carrara
- Società Italiana di Reumatologia, Unità Epidemiologica, Milano
| | | | - Alessandro Mathieu
- Rheumatology Unit, University of Cagliari and AOU University Clinic, Cagliari
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Piga M, Arnaud L. The Main Challenges in Systemic Lupus Erythematosus: Where Do We Stand? J Clin Med 2021; 10:E243. [PMID: 33440874 PMCID: PMC7827672 DOI: 10.3390/jcm10020243] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an immune-mediated multi-systemic disease characterized by a wide variability of clinical manifestations and a course frequently subject to unpredictable flares. Despite significant advances in the understanding of the pathophysiology and optimization of medical care, patients with SLE still have significant mortality and carry a risk of progressive organ damage accrual and reduced health-related quality of life. New tools allow earlier classification of SLE, whereas tailored early intervention and treatment strategies targeted to clinical remission or low disease activity could offer the opportunity to reduce damage, thus improving long-term outcomes. Nevertheless, the early diagnosis of SLE is still an unmet need for many patients. Further disentangling the SLE susceptibility and complex pathogenesis will allow to identify more accurate biomarkers and implement new ways to measure disease activity. This could represent a major step forward to find new trials modalities for developing new drugs, optimizing the use of currently available therapeutics and minimizing glucocorticoids. Preventing and treating comorbidities in SLE, improving the management of hard-to-treat manifestations including management of SLE during pregnancy are among the remaining major unmet needs. This review provides insights and a research agenda for the main challenges in SLE.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, 09042 Cagliari, Italy;
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 67000 Strasbourg, France
- Centre National de Références des Maladies Systémiques et Auto-immunes Rares Est Sud-Ouest (RESO), 67000 Strasbourg, France
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Kernder A, Elefante E, Chehab G, Tani C, Mosca M, Schneider M. The patient's perspective: are quality of life and disease burden a possible treatment target in systemic lupus erythematosus? Rheumatology (Oxford) 2020; 59:v63-v68. [PMID: 33280017 PMCID: PMC7719037 DOI: 10.1093/rheumatology/keaa427] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/16/2020] [Indexed: 12/12/2022] Open
Abstract
A few decades ago, the therapy goal of patients with systemic lupus erythematosus (SLE) was survival and the prevention of organ failure. Today, clinical remission and low disease activity are believed to be the optimal therapeutic targets. These aims are difficult to reach for many patients, but they still do not address the health-related quality of life (QoL) that is significantly impaired in SLE patients. Even in the state of remission, QoL and fatigue are insufficient controlled. Thus, patient-oriented research is essential to design new strategies for the management of lupus patients. The INTEGRATE project analyses the patients' and physicians' perspectives to pave the way to design an innovative therapeutic strategy for lupus and focuses on the multifaceted dimensions of the disease burden. Shared decision making (SDM) could include the patient's perspective of SLE to treatment strategy and consider QoL and the burden of lupus into the process of therapy decision.
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Affiliation(s)
- Anna Kernder
- Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gamal Chehab
- Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matthias Schneider
- Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
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Golder V, Tsang-A-Sjoe MWP. Treatment targets in SLE: remission and low disease activity state. Rheumatology (Oxford) 2020; 59:v19-v28. [PMID: 33280016 PMCID: PMC7719036 DOI: 10.1093/rheumatology/keaa420] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/16/2020] [Indexed: 12/29/2022] Open
Abstract
Treat-to-target strategies have changed the approach to management of many chronic conditions, with improvements in patient outcomes. The key to success of treat to target is the availability of validated treatment endpoints, which have been difficult to derive for SLE, a condition notorious for its heterogeneity. This review will focus on the development and validation of the definitions of remission in SLE framework and the lupus low disease activity state. Lupus low disease activity state is more attainable than remission, with a stepwise concentric relationship between the target states indicating increasing stringency. Both lupus low disease activity state and definitions of remission in SLE remission have been proven to be associated with reduction in disease flares, reduced risk of accrual of irreversible end organ damage, and improvement in patient reported outcomes. These endpoints have therefore provided the key for the development of a treat-to-target approach in clinical practice in SLE and for the design of future clinical trials.
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Affiliation(s)
- Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Michel W P Tsang-A-Sjoe
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands
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45
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2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2020; 1:5-23. [DOI: 10.2478/rir-2020-0009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023]
Abstract
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that represents a prodigious challenge of diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established to develop an evidence-based diagnosis and treatment guideline for patients with SLE in PR China. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the strength of recommendations. The guideline was reported following the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. In this guideline, we provided recommendations for SLE classification criteria, disease activity monitoring and assessment, medication administration and considerations for SLE patients with organs and systems involved, and management of special populations such as SLE patients in the setting of pregnancy. This guideline serves as an evidence-based tool for Chinese clinicians to diagnose and treat patients with SLE.
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Mathian A, Pha M, Amoura Z. [Therapeutic de-escalation in systemic lupus erythematosus in remission]. Rev Med Interne 2020; 41:795-799. [PMID: 33234319 DOI: 10.1016/j.revmed.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Affiliation(s)
- A Mathian
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - M Pha
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - Z Amoura
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France.
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Floris A, Piga M, Perra D, Chessa E, Congia M, Mathieu A, Cauli A. Treatment Target in Newly Diagnosed Systemic Lupus Erythematosus: The Association of Lupus Low Disease Activity State and Remission With Lower Accrual of Early Damage. Arthritis Care Res (Hoboken) 2020; 72:1794-1799. [PMID: 31600023 DOI: 10.1002/acr.24086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 10/01/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare the effect of achievement and maintenance of Lupus Low Disease Activity State (LLDAS) and clinical remission (CR) in preventing early damage accrual in patients with systemic lupus erythematosus (SLE). METHODS In a monocentric cohort of 116 newly diagnosed SLE patients, LLDAS and CR achievement at 6 months (T1) after treatment initiation and their maintenance over the next 12 months were assessed. Early damage was recorded after 18 months of follow-up (T2) using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. Univariate and multivariate analyses were performed to evaluate the association of LLDAS and CR with early damage. RESULTS LLDAS was significantly more attained than CR both at T1 (42.2% versus 21.6% of patients; P < 0.001) and T2 (46.6% versus 31.9%; P = 0.022). The overlap rate between persistent LLDAS and persistent CR was 41.7% (n = 15). On multivariate analysis, achievement of CR (odds ratio [OR] 0.07 [95% confidence interval (95% CI) 0.01-0.59], P = 0.015) and LLDAS (OR 0.25 [95% CI 0.06-0.99], P = 0.049) at T1 were independently associated with lower accrual of early damage. Patients who achieved LLDAS (including CR) at T1 and steadily persisted in this condition until T2 developed significantly less damage compared to those who failed to maintain it during the T1-T2 interval (P = 0.003), those who achieved it later than T1 (P < 0.001), or those who had never been in this condition (P < 0.001). CONCLUSION Although CR is recommended as the primary treatment target in SLE, LLDAS represents a valid alternative in the early stage of SLE management. LLDAS and CR maintenance should be targeted to prevent damage.
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Affiliation(s)
| | - Matteo Piga
- AOU University Clinic of Cagliari, Monserrato, Italy
| | - Daniela Perra
- AOU University Clinic of Cagliari, Monserrato, Italy
| | | | - Mattia Congia
- AOU University Clinic of Cagliari, Monserrato, Italy
| | | | - Alberto Cauli
- AOU University Clinic of Cagliari, Monserrato, Italy
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Yang Z, Cheng C, Wang Z, Wang Y, Zhao J, Wang Q, Tian X, Hsieh E, Li M, Zeng X. Prevalence, predictors and prognostic benefits of remission achievement in patients with systemic lupus erythematosus: a systematic review. Arthritis Care Res (Hoboken) 2020; 74:208-218. [PMID: 32986933 DOI: 10.1002/acr.24464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/13/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To systematically review and evaluate the prevalence, potential predictors and prognostic benefits of remission achievement in patients with systemic lupus erythematosus (SLE). METHODS Studies reporting prevalence, predictors and prognostic benefits of remission in adult SLE patients were searched and selected from Pubmed and EMBASE databases. Studies were reviewed for relevance and quality. Two reviewers independently assessed studies and extracted data. RESULTS Data from forty-one studies including 17270 patients were included and analyzed. Although no consensus has been achieved on the definition of remission, clinical disease activity, serological activity, duration and treatment are agreed to be critical components of defining remission status. In most studies published in the recent 5 years, 42.4% to 88% patients achieved and maintained the remission status for one year, and 21.1% to 70% for at least 5 years. Factors associated with remission included older age at diagnosis, lower baseline disease activity and absence of major organ involvement, while positive serological results were shown to be negatively associated with remission. Remission-especially prolonged remission-when achieved, demonstrated an association with lower accrual of damage and better quality of life among patients with SLE. CONCLUSIONS Remission is an achievable and desirable target for SLE patients, proven to be associated with prognostic benefits. Further development and assessment of a clear remission definition, a risk stratification model as well as a full algorithm with frequency of monitoring, timepoints for treatment adjustment and drug withdrawal are required.
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Affiliation(s)
- Ziyi Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Cheng Cheng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ziqian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences & School of Basic Medicine Peking, Union Medical College, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Evelyn Hsieh
- Section of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Clinical characteristics of systemic lupus erythematosus patients in long-term remission without treatment. Clin Rheumatol 2020; 39:3365-3371. [PMID: 32870418 DOI: 10.1007/s10067-020-05379-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the clinical and serological characteristics of patients with SLE who reached a state of sustained remission for more than 10 years in the absence of treatment. METHODS From a retrospective cohort of 2121 patients, 44 cases with sustained remission (PtRem) were identified and compared with 88 patients whose course has been chronically active (PtAct).The clinical and serological characteristics were analyzed, as well as the treatment of each group at the beginning of the disease and during its evolution. RESULTS Older age at disease onset was associated with a tendency to reach a state of prolonged remission. These patients also had a higher frequency of thrombocytopenia at the beginning of the disease 34.1% vs 10.2% (p < 0.001). PtAct had a significantly higher initial SLEDAI compared with cases (10.4 ± 5.6 vs 14.1 ± 5.8; p < 0.001). PtRem had a higher initial frequency of anti-β2 GP1 IgG antibodies. Also, 25% of these patients were serologically active. We did not find differences in the initial treatment between both groups. The accumulated damage measured by SLICC/ACR damage index at the end of the study was significantly less in the patients who remained in prolonged remission. CONCLUSIONS Although patients with SLE who achieve prolonged remission have some different characteristics at baseline compared with PtAct, it is not possible to identify a characteristic phenotype for the former. Achieving a state of prolonged remission should always be the goal in patients with SLE. Key Points • SLE patients can reach a very prolonged state of remission, free of treatment, including antimalarials, for at least 10 years. • Venous thromboembolism and thrombocytopenia are commonly present in patients that achieved remission. • The presence of serological markers of activity, even after 10 years in remission, is a risk factor for relapse.
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Saccon F, Zen M, Gatto M, Margiotta DPE, Afeltra A, Ceccarelli F, Conti F, Bortoluzzi A, Govoni M, Frontini G, Moroni G, Dall'Ara F, Tincani A, Signorini V, Mosca M, Frigo AC, Iaccarino L, Doria A. Remission in systemic lupus erythematosus: testing different definitions in a large multicentre cohort. Ann Rheum Dis 2020; 79:943-950. [DOI: 10.1136/annrheumdis-2020-217070] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/13/2020] [Accepted: 04/01/2020] [Indexed: 11/03/2022]
Abstract
ObjectivesRemission in systemic lupus erythematosus (SLE) is defined through a combination of ‘clinical SLE Disease Activity Index (cSLEDAI)=0’, ‘physician's global assessment (PGA) <0.5’ and ‘prednisone (PDN) ≤5 mg/day’. We investigated the performance of these items, alone or in combination, in defining remission and in predicting SLICC/ACR Damage Index.MethodsWe tested seven potential definitions of remission in SLE patients followed-up for ≥5 years: PDN ≤5 mg/day; PGA <0.5; cSLEDAI=0; PGA <0.5 plus PDN ≤5 mg/day; cSLEDAI=0 plus PGA <0.5; cSLEDAI=0 plus PDN ≤5 mg/day; cSLEDAI=0 plus PDN ≤5 mg/day plus PGA <0.5. The effect of these definitions on damage was evaluated by Poisson regression analysis; the best performance was identified as the lowest Akaike and Bayesian information criterion (AIC and BIC). Positive and negative predictive values in identifying no damage increase were calculated.ResultsWe included 646 patients (mean±SD disease duration 9.2±6.9 years). At multivariate analysis, ≥2 consecutive year remission according to all definitions protected against damage (OR, 95% CI: PGA <0.5 0.631, 0.444 to 0.896; cSLEDAI=0 0.531, 0.371 to 0.759; PGA <0.5 plus PDN ≤5 mg/day 0.554, 0.381 to 0.805; cSLEDAI=0 plus PGA <0.5 0.574, 0.400 to 0.826; cSLEDAI=0 plus PDN ≤5 mg/day 0.543, 0.376 to 0.785; cSLEDAI=0 plus PDN ≤5 mg/day plus PGA <0.5 0.532, 0.363 to 0.781, p<0.01 for all), except PDN ≤5 mg/day, which required four consecutive years (OR 0.534, 95% CI 0.325 to 0.877, p=0.013). Positive and negative predictive values were similar; however, cSLEDAI=0 showed the best performance (AIC 1082.90, BIC 1109.72, p<0.0001). Adding PGA <0.5 and/or PDN ≤5 mg/day to cSLEDAI=0 decreased remission duration (−1.8 and −1.5 year/patient, respectively) without increasing cSLEDAI=0 performance in predicting damage accrual.ConclusionscSLEDAI=0 is the most attainable definition of remission, while displaying the best performance in predicting damage progression in the short-to-mid-term follow-up.
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