Response to: 'Comment on: 'Lupus Low Disease Activity State(LLDAS) attainment discriminates responders in a systemic lupus erythematosus trial: post-hocanalysis of the Phase IIb MUSE trial of anifrolumab' by Eric Morand et al' by Isenberg

Pragmatic targets for moderate/severe SLE and their implications for clinical care and trial design: sustained DORIS or LLDAS for at least 6 months is sufficient while their attainment for at least 24 months ensures high specificity for damage-free progression

OBJECTIVES

Treatment targets in systemic lupus erythematosus (SLE) have been validated in unselected-in terms of severity-cohorts, which limits their generalisability. We assessed remission (Definition of Remission in SLE (DORIS)) and Lupus Low Disease Activity State (LLDAS) in a historical cohort of 348 patients with active moderate-to-severe disease and median follow-up of 5 years.

METHODS

Active SLE was defined as Physician Global Assessment ≥1.5 and/or SLE Disease Activity Index 2000 ≥6, requiring therapy intensification. DORIS/LLDAS, organ damage, flares and adverse events were monitored. Shared frailty survival, generalised linear models and K-means clustering were applied.

RESULTS

Sustained DORIS and LLDAS for ≥6 months occurred in 41.1% and 80.4%, respectively, and resulted in reduced damage accrual (HR: 0.58; 95% CI 0.36 to 0.93 and 0.61; 0.43 to 0.86) and severe flares (HR: 0.14; 0.08 to 0.27 and 0.19; 0.13 to 0.27). LLDAS without DORIS was also protective (HR: 0.65; 0.43 to 0.98 for damage, 0.49; 0.36 to 0.67 for flares). Models fitting increasing duration of targets showed that DORIS ≥50% and LLDAS ≥60% of time, or alternatively, ≥24 and ≥36 months, achieved optimal balance between feasibility (20.2-41.7%) and specificity (73.3-86.1%) for damage-free outcome. These targets were linked to reduced serious adverse events (risk ratio (RR): 0.56-0.71), hospitalisation (RR: 0.70) and mortality (RR: 0.06-0.13). Patients with predominant arthritis and mucocutaneous disease experienced reduced DORIS/LLDAS, compared with counterparts with major organ involvement. Conventional drugs were more frequently used in the former group, whereas potent immunosuppressive/biological agents in the latter.

CONCLUSIONS

In moderate-to-severe SLE, sustained DORIS/LLDAS for at least 6 months is sufficient, while attainment for at least 24 months ensures higher specificity for damage-free progression, thus facilitating treat-to-target strategies and clinical trials. Arthritis and skin disease represent unmet therapeutic needs that could benefit from novel biologics.

Viewpoint on anifrolumab in patients with systemic lupus erythematosus and a high unmet need in clinical practice

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterised by unpredictable flares. Many patients with SLE are unable to achieve the recommended treatment goal of remission or the intermediate, yet still clinically beneficial, goal of Lupus Low Disease Activity State (LLDAS) with standard of care (SoC) treatments. LLDAS is an emerging treat-to-target goal in SLE with the aim of reducing organ damage and mortality. A high unmet need remains in SLE and mainstay glucocorticoid treatment is associated with unacceptable toxicity. The recently approved type I interferon receptor antagonist anifrolumab is a new treatment option for this historically underserved patient population. In phase 3 trials, a higher percentage of patients on anifrolumab achieved remission, as defined by the Definition Of Remission In SLE (DORIS), and LLDAS compared with placebo. Real-world clinical experience with anifrolumab use is still limited. Until real-world study results and updated treatment guidelines are available, personal expert clinical experience supported by data may inform clinical decision-making. This viewpoint article discusses four example patient types that could be considered for anifrolumab treatment based on (1) high-risk features early in the disease course, (2) inability to achieve and (3) maintain at least LLDAS, or (4) a desire to reduce or stop SoC. These patients with high unmet need may benefit from the addition of anifrolumab to SoC to achieve or maintain the therapeutic goals of LLDAS or DORIS remission.