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

Differences in myocardial involvement between new onset and longstanding systemic lupus erythematosus patients assessed by cardiovascular magnetic resonance

Objectives

Subclinical myocardial involvement is common in systemic lupus erythematosus (SLE), but differences between new onset and longstanding SLE are not fully elucidated. This study compared myocardial involvement in new onset versus longstanding SLE using cardiovascular magnetic resonance (CMR).

Materials and methods

We prospectively enrolled 24 drug-naïve new onset SLE patients, 27 longstanding SLE patients, and 20 healthy controls. All participants underwent clinical evaluation and CMR examination. We analyzed left ventricular (LV) morphological, functional parameters, and tissue characterization parameters: native T1, T2, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE).

Results

Both new onset and longstanding SLE groups showed elevated native T1, T2, and ECV values compared to the control group (all P < 0.05). Additionally, the new onset SLE group exhibited higher T2 values compared to the longstanding SLE group [55.3 vs. 52.8 ms, P < 0.05]. The new onset group also demonstrated higher left ventricular (LV) end-diastolic volume index (LVEDVi), LV end-systolic volume index (LVSVi), and LV mass index (LVMi) than controls (all P < 0.05), with LVEDVi significantly higher than in the longstanding group (P < 0.05).

Conclusion

CMR tissue characterization imaging can detect early myocardial involvement in patients with new onset and longstanding SLE. Patients with new onset SLE exhibit more pronounced myocardial edema than those with longstanding SLE. This suggests that SLE patients are at risk of myocardial damage at various stages of the disease, underscoring the need for early monitoring and long-term management to prevent the progression of myocardial remodeling.

Framework for implementing treat-to-target in systemic lupus erythematosus routine clinical care: consensus statements from an international task force

Implementation of Treat-to-Target (T2T) in routine clinical practice remains low in systemic lupus erythematosus (SLE). Real-world data reveal excessive use of glucocorticoids (GCs) and frequently inadequate disease control. Here, an international task force convened to develop a consensus framework for implementing T2T in routine clinical care of adult patients with SLE. This T2T task force comprised an international panel of 22 physicians involved in the care of SLE and 3 lupus patient research partners. Following a scoping review and online discussions, during which definitions and instruments available for T2T in SLE were examined, the panel developed potential framework statements for implementing T2T in SLE, which were extensively discussed before being agreed upon by Delphi consensus. Additionally, the current challenges of implementing T2T in SLE and how future research may address these issues were analyzed. The framework comprises 5 overarching principles and 11 statements. Despite the absence of formal evidence that T2T offers superiority to conventional SLE management, T2T in SLE has been recommended for over a decade. This task force offers a framework for effectively implementing T2T in SLE from a real-life perspective, informing a wide range of physicians, including those outside the limited circle of lupus specialists.

Plasma C4d levels correlate with treatment response and renal activity in proliferative lupus nephritis

OBJECTIVE

Investigation of complement factors in lupus nephritis (LN) in relation to treatment response and the impact of underlying genetics of C4.

METHODS

Seventy-seven patients with active LN confirmed by a kidney biopsy and in whom second biopsies had been performed after immunosuppressive treatment were included. Complement factors C3, C4, C4d and C4d/C4 ratio were evaluated at the biopsy time-points. The gene copy number variations of C4 (C4A and C4B) were also investigated.

RESULTS

At baseline, 60 patients had class III/IV±V, proliferative LN (PLN) and 17 class V, membranous LN (MLN). Levels of C3 and C4 increased and C4d and C4d/C4 decreased after treatment (p< 0.0001), observed in treatment-responding PLN patients but not in MLN. C4d, C4 and C4d/C4 at second biopsies were associated with clinical response in PLN, and low C4d levels were found in PLN with histopathological response (p= 0.008). Renal activity index at second biopsies correlated to C4d and C4d/C4, but not to C3 or C4. C4 gene copy number variations were not associated with clinical or histopathological response.

CONCLUSION

All complement markers were affected by immunosuppressive therapy and associated with response to therapy. Levels of C4d and C4d/C4 at follow-up biopsies showed a strong association with both clinical and histopathological response in PLN. The correlation with elevated C4d and C4d/C4 and persisting high activity index on repeated biopsies strengthens the findings on C4d as a promising biomarker for treatment response in PLN. The C4 genetic variations did not influence C4 levels or response to treatment.

Epidemiology and effect of psychiatric comorbidities on survival rates in patients with systemic sclerosis: A nationwide population-based cohort study

BACKGROUND

Systemic sclerosis (SSc) is a chronic, disabling connective tissue disease with a considerable psychological burden. While studies suggest a higher prevalence of psychiatric disorders in SSc, most have small sample sizes.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 3270 SSc patients from the catastrophic illness registry and matched them 1:4 by age and sex with 13,080 controls. We compared the incidence rate ratios (IRRs) of new psychiatric disorder diagnoses between the two groups and analyzed risk factors using a Cox proportional hazards model. Kaplan-Meier analysis and log-rank test were used to compare survival in SSc patients with and without psychiatric conditions (matched at a 1:4 ratio by age, sex and CCI). We compared psychiatric disorder incidence rates.

RESULTS

The SSc group had a significantly higher incidence of psychiatric disorders than controls (IRR = 1.66, p < 0.001). In SSc patients, treatment with an oral daily steroid dose of ≥7.5 mg (hazard ratio [HR] = 1.71, p = 0.010), intravenous steroid pulse therapy (HR = 2.34, p < 0.0042), or D-penicillamine (HR = 1.60, p < 0.001) served as an independent risk factor for psychiatric comorbidities. SSc patients with psychiatric comorbidities had significantly lower survival rates than those without.

CONCLUSIONS

Patients with SSc are at an increased risk of psychiatric comorbidities, which can negatively affect their survival rates. Treatment with a daily oral steroid dose of ≥7.5 mg, intravenous steroid pulse therapy, or D-penicillamine is a risk factor for psychiatric comorbidities in SSc.

Role of belimumab in recurrent spontaneous abortions amongst patients with lymphocyte dysfunction: a retrospective case-control study

OBJECTIVE

In order to examine the impact of belimumab on recurrent spontaneous abortion (RSA) women exhibiting B lymphocyte dysfunction.

METHODS

This study conducted a retrospective case-control analysis of RSA patients with confirmed B lymphocyte dysfunction. The study included 102 women who had experienced at least two consecutive miscarriages and demonstrated elevated peripheral blood B cell percentages and/or counts. Participants were separated into two distinct groups: the belimumab group (n = 51), which received basic treatment supplemented with belimumab (BENLYSTA) at a dosage of 10 mg/kg BW at 2-week intervals for the first 3 doses and at 4-week intervals thereafter, from the end of menstrual period until the 12th week of pregnancy, if necessary; and the control group (n = 51), which received only standard treatment. Comparisons of Pregnancy outcomes, B cell percentage, B cell count and adverse reactions were made between 2 groups.

RESULTS

Healthy newborns were delivered by 45 participants (88.23%) in belimumab group and 36 participants (70.59%) in control group [P = 0.048, odds ratio (OR) = 3.13; 95% confidence interval (CI) (1.10-8.87)]. The belimumab group exhibited significantly lower peripheral blood B cell percentage and B cell count compared to the control group during gestational weeks 2-12 (P < 0.05).

CONCLUSION

The findings suggest that belimumab is both safe and effective for treating RSA with lymphocyte dysfunction, indicating its potential as a therapeutic strategy for RSA.

Unlocking the Power of the Mediterranean Diet: Two in One-Dual Benefits for Rheumatic and Thyroid Autoimmune Diseases

In recent years, autoimmune diseases are becoming more and more prevalent worldwide, with this rapid rise being influenced by environmental factors linked to lifestyle changes in modern societies. In this context, the role of diet has been the topic of extensive research as evidence has mounted that particular dietary patterns may contribute to or modulate autoimmunity. The present review specifically focuses on the Mediterranean diet (MD) as a whole dietary pattern, and on its peculiar components, such as n-3 polyunsaturated fatty acids (PUFAs), polyphenols and fiber. We explored their potential benefits in a spectrum of both systemic and organ-specific autoimmune disorders, including rheumatic diseases (like rheumatic arthritis and systemic lupus erythematosus), and thyroid diseases (like Hashimoto's thyroiditis), since they often occur in the same individuals. Here, we offer a comprehensive review about the influence of dietary factors on these autoimmune diseases and potential translation into therapeutic interventions, as an adjuvant therapeutic approach to improve autoimmunity-related outcomes.

Glucocorticoid in systemic lupus erythematosus: the art beyond science

INTRODUCTION

Glucocorticoid (GC) remains the main stay of treatment for systemic lupus erythematosus (SLE) but is associated with a myriad of untoward effects. On the other hand, withdrawal of maintenance immunosuppression, including low-dose GCs, carries a risk of SLE flare.

AREAS COVERED

The molecular mechanisms of GCs and their implications for dosing strategies in clinical practice are discussed. Evidence regarding withdrawal of maintenance immunosuppression in SLE is reviewed.

EXPERT OPINIONS

The initial GC regimens for different manifestations of SLE are heterogeneous, with no major randomized controlled trials (RCTs) on their efficacy and toxicities available. RCTs on withdrawal of immunosuppressive drugs in quiescent SLE are inconsistent but appear to show an increase in disease flares, with risk factors being younger age, renal disease, cessation of hydroxychloroquine, shorter duration of remission, serological activity, and an abrupt tapering regime. The lowest effective doses of GC and immunosuppressive drugs should be adopted, and the decision to withdraw immunosuppression should be individualized. Newer strategies for GC sparing, including combination therapy of immunosuppressive and biological/targeted agents, and the use of methylprednisolone pulses for initial therapy of less serious manifestations of SLE, could ameliorate the toxicities of immunosuppression and help advance to the ultimate target of drug-free remission.

Concomitant Systemic Lupus Erythematosus and Glanzmann Thrombocytopenia: A Case Report and Literature Review

Background: Glanzmann thrombasthenia (GT) is a rare disease that manifests with bleeding in different parts such as epistaxis and bruising. GT can be congenital or acquired. Systemic lupus erythematosus (SLE) is an autoimmune disorder. It is mentioned that the acquired type can be associated with other disorders like malignancies and autoimmune disorders. There is no report about the co-occurrence of congenital GT with SLE. Case Report: In this report, we present this co-occurrence in a girl. An 11-year-old girl was referred to our clinic with severe and uncontrolled epistaxis. She had a history of recurrent epistaxis, gastrointestinal bleeding, and bruising. She also had a malar rash and generalized body pain. She was admitted, and after clinical and laboratory assessments, a co-occurrence of congenital GT with SLE was diagnosed. Conclusion: The co-occurrence of congenital GT and SLE has not been reported until now. Patients with this presentation should be closely followed up because the risk of bleeding is high for them.

Nanoparticles encapsulating antigenic peptides induce tolerogenic dendritic cells in situ for treating systemic lupus erythematosus

Using Tetrahedral framework nucleic acids, we combined antigenic peptides to create the "DART" vaccine: DNA framework-Antigenic peptide-RNA modification-Targeting aptamer coupling. Generating antigen-specific tolerogenic dendritic cells (tolDCs), for systemic lupus erythematosus (SLE) is a potential therapeutic strategy for addressing compromised autoimmune tolerance. However, simple antigenic peptides degrade easily, lack specificity for delivery to dendritic cells (DCs), and cannot transform DCs to tolDCs. Therefore, this study aims to employ DART to generate tolDCs and compare DART-treated DCs to tolDCs. DART improved peptide stability, specifically targeted DCs, induced tolDCs in situ, and showed promising outcomes in mitigating SLE symptoms in the MRL/lpr mouse model. DART effectively normalized the plasma cytokine levels, glomerulonephritis, and joint lesions in MRL/lpr mice. These findings highlight the potential of the DART vaccine to induce transformation of DCs to tolDCs and address SLE symptoms, suggesting novel therapeutic utility. These findings may advance vaccine design for various autoimmune diseases.

Comparative evaluation of three anti-dsDNA antibody detection methods in systemic lupus erythematosus: insights from a large monocentric cohort

Background

Anti-double-stranded DNA (anti-dsDNA) antibodies at abnormal titer are of considerable diagnostic value for systemic lupus erythematosus (SLE). Current assays detecting anti-dsDNA antibodies show divergent properties, emphasizing the importance of selecting suitable assays. This study aims to investigate the diagnostic performance of indirect immunofluorescence (IIF), digital liquid chip method (DLCM), chemiluminescence immunoassay (CLIA), and their combinations for detecting anti-dsDNA antibodies in SLE.

Methods

We conducted a retrospective, single-center study from 2022 to 2023 which included 3429 samples: 1773 from patients with SLE and 1656 from controls with rheumatoid arthritis (RA) and Sjögren's syndrome (SS). Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) for anti-dsDNA detection by IIF, DLCM, and CLIA were calculated. Cohen's kappa coefficient was used to evaluate inter-method agreement. The correlations between anti-dsDNA concentration and SLEDAI-2k scores/renal involvement were assessed.

Results

Among individual assays, IIF demonstrated the highest specificity (98.31%) and PPV (96.10%) but lower sensitivity (38.92%) compared to CLIA (41.57%) and DLCM (43.65%) (p < 0.05). Combining two assays significantly improved sensitivity while maintaining specificity>95%. The combination of IIF and DLCM achieved a sensitivity of 52.2% and an AUC of 0.76. Substantial agreement was observed between DLCM and CLIA (κ = 0.78), whereas agreement between IIF and the other assays was moderate (κ = 0.65-0.66). In a longitudinal analysis of 88 SLE patients, CLIA and DLCM detected antibody fluctuations more reliably than IIF. Anti-dsDNA levels by DLCM or CLIA positively correlated with SLEDAI-2K scores (R=0.42 and 0.29, p<0.05). Both IIF and CLIA methods showed significant differences between the SLE patients with and without renal involvement (p < 0.05). The combination of two assays provided higher sensitivity than single assays (p<0.001) in renal involvement subgroups.

Conclusion

Our findings demonstrate that DLCM performs comparably to CLIA, supporting its clinical potential. Moreover, combining assays significantly enhances diagnostic sensitivity, particularly in subgroups with renal involvement.

Improving Phenotyping of Patients With Immune-Mediated Inflammatory Diseases Through Automated Processing of Discharge Summaries: Multicenter Cohort Study

BACKGROUND

Valuable insights gathered by clinicians during their inquiries and documented in textual reports are often unavailable in the structured data recorded in electronic health records (EHRs).

OBJECTIVE

This study aimed to highlight that mining unstructured textual data with natural language processing techniques complements the available structured data and enables more comprehensive patient phenotyping. A proof-of-concept for patients diagnosed with specific autoimmune diseases is presented, in which the extraction of information on laboratory tests and drug treatments is performed.

METHODS

We collected EHRs available in the clinical data warehouse of the Greater Paris University Hospitals from 2012 to 2021 for patients hospitalized and diagnosed with 1 of 4 immune-mediated inflammatory diseases: systemic lupus erythematosus, systemic sclerosis, antiphospholipid syndrome, and Takayasu arteritis. Then, we built, trained, and validated natural language processing algorithms on 103 discharge summaries selected from the cohort and annotated by a clinician. Finally, all discharge summaries in the cohort were processed with the algorithms, and the extracted data on laboratory tests and drug treatments were compared with the structured data.

RESULTS

Named entity recognition followed by normalization yielded F1-scores of 71.1 (95% CI 63.6-77.8) for the laboratory tests and 89.3 (95% CI 85.9-91.6) for the drugs. Application of the algorithms to 18,604 EHRs increased the detection of antibody results and drug treatments. For instance, among patients in the systemic lupus erythematosus cohort with positive antinuclear antibodies, the rate increased from 18.34% (752/4102) to 71.87% (2949/4102), making the results more consistent with the literature.

CONCLUSIONS

While challenges remain in standardizing laboratory tests, particularly with abbreviations, this work, based on secondary use of clinical data, demonstrates that automated processing of discharge summaries enriched the information available in structured data and facilitated more comprehensive patient profiling.

IL-10 in Systemic Lupus Erythematosus: Balancing Immunoregulation and Autoimmunity

Interleukin-10 (IL-10) presents a dual role in systemic lupus erythematosus (SLE), illustrating pro-inflammatory and anti-inflammatory effects. This study addressed the possible associations between serum IL-10 levels and demographic characteristics, laboratory parameters, organ manifestations, disease activity, and treatment response in SLE patients. A total of 88 SLE patients from the Rheumatology Clinic of the Clinical Rehabilitation Hospital, Iași, were enrolled. Disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Serum cytokine levels were measured using an enzyme-linked immunosorbent assay (ELISA). Serum IL-10 levels were significantly higher in males compared to females (47.62 pg/mL vs. 13.24 pg/mL, p = 0.011) but not significantly associated with age or disease duration. However, IL-10 showed positive correlations with inflammatory markers and autoantibodies, including C-reactive protein (p = 0.002), IL-6 (p = 0.01), ANA (p = 0.014), and anti-SSB antibodies (p = 0.005). Our findings indicate that IL-10 may be involved in inflammatory and immune processes in SLE, as evidenced by its significant correlations with specific autoantibodies and inflammatory markers in our study. However, IL-10 did not correlate with disease activity, organ involvement, or treatment response. These results underline the participation of IL-10 in SLE and emphasize the need for further research to clarify its potential as a biomarker or therapeutic target.

Headache in patients with systemic lupus erythematosus: A matched case-control study

OBJECTIVES

To compare the prevalence and characteristics of headaches between patients with systemic lupus erythematosus (SLE) and people without the disease and to assess whether there was a relationship between headaches and disease activity.

BACKGROUND

Headache is a common symptom in patients with SLE; however, the effect of SLE on headaches is not fully known.

METHODS

This was a case-control study. Individuals with and without SLE matched by age and sex were compared. All participants were assessed by a neurologist. A semi-structured questionnaire, the six-item Headache Impact Test (HIT-6) and the Hospital Anxiety and Depression Scale were used. Disease activity was measured by a rheumatologist using the Physician Global Assessment (PGA) and quantified using the modified Systemic Lupus Erythematosus Disease Activity Index 2000 scale (modified SLEDAI-2K). Data were collected between November 2021 and January 2023.

RESULTS

A total of 228 individuals were included, 114 in each group. The SLE group presented with more moderate/severe headache attacks than the controls (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.21-4.95; p = 0.013). When comparing patients with active SLE and those without disease activity, there was no difference in the prevalence (OR 1.48, 95% CI 0.38-5.74), type (migraine: OR 1.69, 95% CI 0.71-3.99; tension-type headache: OR 0.64, 95% CI 0.25-1.68), frequency (4; 2-15 vs. 3; 1-12 days/month; p = 0.250), intensity (moderate/severe intensity: OR 0.59, 95% CI 0.19-1.82), or impact of headache (HIT-6: 61; 50-65 vs. 56; 45-63; p = 0.278). The magnitude of SLE activity (modified SLEDAI-2K) demonstrated no statistically significant association with the impact (standardized beta coefficient: 0.02, 95% CI -0.05 to 0.09; p = 0.792) or monthly frequency of headache (standardized beta coefficient: 0.09, 95% CI -0.08 to 0.26; p = 0.275).

CONCLUSIONS

Headache is a common symptom in SLE, although the prevalence was similar to that of the controls without the disease. While patients with SLE had more intense headache attacks than the controls without SLE, there was no association between headache and SLE activity.

Efficacy, safety and optimal intervention of belimumab for proliferative lupus nephritis patients in real-world settings: LOOPS registry

OBJECTIVES

This study investigated the efficacy, safety and predictive factors of belimumab (BEL) in induction therapy for patients with proliferative lupus nephritis (LN) in real-world settings.

METHODS

Patients with biopsy-proven ISN/RPS class III or IV LN, with or without coexisting class V LN, who underwent standard of care (SoC), glucocorticoid (GC) and either mycophenolate mofetil or cyclophosphamide treatments were included. Participants were treated with SoC (SoC group, n = 32) or BEL and SoC (BEL+SoC group, n = 30). The primary end point was complete renal response (CRR) at 52 weeks.

RESULTS

Baseline patient characteristics were not significantly different between the two groups. The 52-week retention rate of BEL was 90.0%. The BEL+SoC group showed significantly higher CRR and primary efficacy renal response achievement at 52 weeks and significantly lower GC dosage, adverse events and Systemic Lupus International Collaborating Clinics damage index scores. Multivariate analysis of CRR achievement at 52 weeks revealed that the lack of estimated glomerular filtration rate (eGFR) improvement at 4 weeks was associated with CRR failure in the SoC group. A shorter duration (cut-off of 42 days) between the start of induction therapy and addition of BEL was also related to the CRR in the BEL+SoC group.

CONCLUSION

BEL, in addition to SoC, controls disease activity, reduces GC use and suppresses organ damage in case of proliferative LN. Earlier BEL induction within 6 weeks may help achieve CRR in treatment-resistant cases without eGFR improvement at 4 weeks after induction therapy.

Belimumab patient profile in Spain: evolution during the last decade and future directions

INTRODUCTION

Belimumab (BEL), an anti B-lymphocyte stimulator monoclonal antibody, is the only approved biological therapy for systemic lupus erythematosus (SLE) and lupus nephritis (LN).

AREAS COVERED

This review discusses BEL's real-world use and its positioning in clinical practice guidelines, focusing on the evolution of its application and patient profile over the last decade in Spain.

EXPERT OPINION

Initially used for refractory and non-major SLE manifestations, BEL's application has expanded. International guidelines now recommend earlier use of BEL in treatment algorithms. With its 2021 approval for LN, BEL is increasingly used for renal manifestations and as a first-line therapy. Safety data confirm its tolerability without a significant increase in severe infections. However, real-world evidence in Spain reveals discrepancies with these recommendations for both SLE and LN. The optimal patient for BEL treatment is one with mild, moderate, or severe SLE that cannot be controlled with hydroxychloroquine (HCQ), with or without glucocorticoids (GC) and immunosuppressants (IS), in patients with a disease duration of ≤2 years, no initial organ damage, GC doses ≥5 mg/day, and a high risk of severe flares. Further studies are needed to determine the optimal timing for BEL initiation to improve patient outcomes and modify the disease course.

Revolutionary Changes in the Management of Lupus Nephritis: Towards De-Glucocorticoid or No-Glucocorticoid

Glucocorticoids (GCs) possess potent anti-inflammatory and immunosuppressive properties and are used to treat various diseases, including systemic autoimmune rheumatic diseases, rheumatoid arthritis, and systemic lupus erythematosus (SLE). However, GCs are associated with several adverse events and are considered risk factors for infections and cardiovascular disorders; furthermore, their application as therapeutics has changed with recent progress in molecular-targeted therapies. Although GCs have been the mainstay of SLE treatment for more than 50 years, the latest European Alliance of Association for Rheumatology recommendations for the management of SLE in 2023 has significantly relegated the use of GCs and recommended that these be used as "bridging therapy" during periods of SLE disease activity. They also recommended the use of GC pulse therapy followed by relatively low doses of GCs even in patients with high disease-activity lupus nephritis, with a focus on the appropriate use of hydroxychloroquine, immunosuppressive drugs, and biological agents. This combination is essential for improving renal survival, minimizing flares, and reducing the side effects of GC. The GC dose was tapered to < 5 mg/day of prednisolone within half a year, maintained for 3 years, and then discontinued with the concomitant use of combination therapies. In contrast to non-renal SLE, the development of more potent molecular targeted therapies for lupus nephritis is required.

An ultra-fast UPLC-MS/MS approach for the quantification of baricitinib in the HLM matrix: greenness assessment with application to in vitro and in silico metabolic stability studies

Baricitinib (Olumiant) is a Janus kinase inhibitor utilized for the management of COVID-19, rheumatoid arthritis, and alopecia areata. It received U.S. Food and Drug Administration approval on May 31, 2018. This work developed a sensitive, rapid, environmentally friendly, and reliable UPLC-MS/MS method for quantifying baricitinib in human liver microsomes, utilized to evaluate the in vitro metabolic stability of baricitinib in HLMs. The StarDrop software, with DEREK and P450 metabolic programs, was employed to detect the structural warnings related to BCB and assess the in silico metabolic lability. The validation of the UPLC-MS/MS approach conformed to U.S. Food and Drug Administration standards for bioanalytical approach validation. The present UPLC-MS/MS method exhibited a wide range of linearity (1.0-3000 ng mL-1) and optimum separation of analytes in an ultra-fast separation time (1 min) and was reproducible and accurate in the absence of human liver microsome matrix effects. Baricitinib and encorafenib (the internal standard) were examined employing an isocratic mobile phase technique on a reversed phase (SB C18) column. This study assessed the accuracy and precision of UPLC-MS/MS methodologies for intra- and inter-day evaluations, which ranged from -1.20% to 8.67% and 0.12% to 11.67%, respectively. The intrinsic clearance of baricitinib was quantified at 27.49 mL min-1 kg-1, while the in vitro half-life was established at 29.50 minutes. In silico analysis proposes that slight structural alterations to the pyrrole ring (88%) and the pyrimidine ring (5%) in drug design may increase safety and metabolic stability related to baricitinib. The evaluation of in silico absorption, distribution, metabolism, excretion, and metabolic stability characteristics for baricitinib is crucial for advancing innovative drug discovery focused on enhancing metabolic stability.

Does hydroxychloroquine reduce the risk of infection in patients with systemic lupus erythematosus? a systematic review and meta-analysis

OBJECTIVES

This study aimed to investigate the anti-infective utility of hydroxychloroquine in patients with systemic lupus erythematosus (SLE) by analyzing published case-control and cohort studies.

METHODS

A systematic literature review was conducted on January 28, 2024, using PubMed, Cochrane, Embase, and Web of Science Core Collection databases. Odds ratios (OR) were used for statistical analysis.

RESULTS

Hydroxychloroquine exhibits a propensity to diminish infection risk in systemic lupus erythematosus patients, albeit without statistical significance (OR = 0.77, 95%CI 0.51-1.18, p = 0.23). Subgroup analyses revealed a significant prevention of serious infections (OR = 0.40, 95%CI 0.25-0.64, p = 0.0001). Interestingly, a potential causal relationship between hydroxychloroquine use and lower infection risk was observed in the cohort studies subgroup (OR = 0.66, 95%CI 0.44-0.99, p = 0.04), but not in the case-control studies subgroup (OR = 1.06, 95%CI 0.63-1.79, p = 0.83). It is important to note the risks associated with high-dose use, such as retinopathy.

CONCLUSIONS

Although hydroxychloroquine tends to reduce infection risk in SLE patients, the evidence is not strong. It can decrease severe infections, but high doses should be used cautiously and selectively in patients with impaired renal function. Further studies are required to establish optimal dosing and efficacy for specific diseases, considering the potential influence of study design on the observed associations between hydroxychloroquine use and infection risk in SLE patients.

Glucocorticoid receptor inhibits Th2 immune responses by down-regulating Pparg and Gata3 in schistosomiasis

Introduction

The Th2 immune response plays a pivotal role in the pathogenesis of schistosomiasis, contributing to the formation of hepatic granulomas and fibrosis. While the glucocorticoid receptor (GR) is a ubiquitously expressed nuclear receptor that mediates anti-inflammatory effects, its impact on Th2 responses in schistosomiasis remains underexplored. Thus, this study aimed to investigate the potential impact of GR activation on the hepatic Th2 immune response in schistosomiasis using the synthetic glucocorticoid dexamethasone.

Method

In vivo, Schistosoma japonicum-infected mice were treated with dexamethasone, while in vitro studies were conducted on Th2 cells. Additionally, RNA sequencing and single-cell sequencing were integrated to identify key transcription factors influenced by GR activation during Th2 cell differentiation, with gene expression levels validated both in vivo and in vitro.

Results

In vivo, GR activation markedly reduced the size of Schistosoma egg granulomas and substantially repressed the transcription of key Th2-related cytokines, such as IL-4, IL-5, and IL-13. In vitro, GR activation inhibited the transcription of IL-4, IL-5, and IL-13, as well as the secretion of IL-4 in Th2 cells. An integrated analysis of RNA sequencing and single-cell sequencing revealed that GR activation downregulated the expression of two major transcription factors, Gata3 and Pparg, which were elevated in infected mouse livers and Th2 cells but decreased following dexamethasone treatment.

Conclusion

GR activation may suppress the Th2 immune response triggered by egg antigens by downregulating the expression of the key transcription factors Gata3 and Pparg. While these findings provide insights into a potential complementary therapeutic strategy, further research is necessary to assess the feasibility and safety of targeting GR activation for the treatment of schistosomiasis.

Targeting autophagy in autoimmune glomerular diseases

Autophagy is a natural process whereby damaged or dying parts of a cell are eliminated and recycled. The term autophagy usually refers to macroautophagy, which is one of three types of autophagy, alongside microautophagy and chaperone-mediated autophagy. Autophagy is activated by adenosine monophosphate-activated protein kinase (AMPK) and inhibited by mammalian target of rapamycin (mTOR) through their interference with Unc-51-like kinase 1 (ULK1). Dysregulated autophagy is deeply involved in autoimmune glomerular diseases. Upregulated autophagy can induce inflammation and activate innate and adaptive immunity. However, autophagy may also exert a protective role on podocytes, enhance endothelial cell function, and preserve proximal tubular epithelial cells during ischemic or endotoxic acute kidney injury (AKI). Hydroxychloroquine (HCQ) can downregulate increased autophagy and is widely used in lupus nephritis. HCQ causes alkalinization, which results in vacuolization of lysosomes and inhibition of their functions. By inhibiting autophagic activity, HCQ may reduce inflammation and innate immunity, inhibit the activation of T cells, restore the T helper 17/T regulator balance, restrict the production of pro-inflammatory cytokines, and modulate co-stimulatory molecules. This reduces the risk of flares, spares the dosage of glucocorticoids, improves lupus activity, and prevents the thrombotic effects of anti-phospholipid antibodies. Recent studies showed that HCQ can also reduce proteinuria in IgA nephropathy (IgAN) and membranous nephropathy (MN). Drugs that improve mitochondrial function or enhance autophagy, such as metformin, sodium-glucose co-transporter 2 (SGLT2) inhibitors or mTOR inhibitors, may exert protective effects on podocytes and reduce proteinuria in MN or focal segmental glomerulosclerosis (FSGS).

Systemic lupus erythematosus: updated insights on the pathogenesis, diagnosis, prevention and therapeutics

Systemic lupus erythematosus (SLE) is a chronic inflammatory illness with heterogeneous clinical manifestations covering multiple organs. Diversified types of medications have been shown effective for alleviating SLE syndromes, ranging from cytokines, antibodies, hormones, molecular inhibitors or antagonists, to cell transfusion. Drugs developed for treating other diseases may benefit SLE patients, and agents established as SLE therapeutics may be SLE-inductive. Complexities regarding SLE therapeutics render it essential and urgent to identify the mechanisms-of-action and pivotal signaling axis driving SLE pathogenesis, and to establish innovative SLE-targeting approaches with desirable therapeutic outcome and safety. After introducing the research history of SLE and its epidemiology, we categorized primary determinants driving SLE pathogenesis by their mechanisms; combed through current knowledge on SLE diagnosis and grouped them by disease onset, activity and comorbidity; introduced the genetic, epigenetic, hormonal and environmental factors predisposing SLE; and comprehensively categorized preventive strategies and available SLE therapeutics according to their functioning mechanisms. In summary, we proposed three mechanisms with determinant roles on SLE initiation and progression, i.e., attenuating the immune system, restoring the cytokine microenvironment homeostasis, and rescuing the impaired debris clearance machinery; and provided updated insights on current understandings of SLE regarding its pathogenesis, diagnosis, prevention and therapeutics, which may open an innovative avenue in the fields of SLE management.

Integrative miRNA-mRNA profiling uncovers mechanisms of belimumab action in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder driven by autoreactive B cells and characterized by the production of pathogenic autoantibodies. Belimumab, an anti-BAFF monoclonal antibody, has demonstrated efficacy in reducing disease activity and corticosteroid use in SLE patients, although responses remain variable. B-cell activating factor (BAFF) is essential for B cell survival and autoantibody production, positioning it as a key target in SLE pathogenesis. MicroRNAs (miRNAs), critical regulators of gene expression and immune homeostasis, have an emerging role in SLE pathophysiology. However, their regulation in response to anti-BAFF therapies, such as belimumab, remains unexplored. This study investigates miRNA-mRNA interactions in T cells, B cells, and myeloid cells from SLE patients before and after belimumab treatment. A total of 79 miRNAs associated with treatment response and 525 miRNA-gene interactions were identified. Validation in 18 SLE responders revealed significant changes in miRNA expression in T and myeloid cells, but not in B cells. Belimumab was found to modulate B cell development by regulating genes such as BLNK, BANK1, and MEF2C, as well as the CD40/CD40L axis. In T cells, miRNAs influenced interferon signaling and inflammatory cytokines via NF-κB activation. Changes in myeloid cells, characterized by the downregulation of KLF13, CCL5, and IL4, appear to be secondary to T cell modulation. These findings provide novel insights into the miRNA-mediated regulatory networks underlying belimumab's immunomodulatory effects in SLE. Further research is required to validate these findings and through in vitro experiments to better understand the role of miRNAs in guiding treatment responses.

Comparison of flares in 85 patients with SLE who maintained, discontinued or reduced dose of hydroxychloroquine during a prospective study of ophthalmological screening for retinopathy (PERFOCTAPS Study)

OBJECTIVE

Little is known about the risk of SLE flares associated with hydroxychloroquine (HCQ) reduction or cessation, especially after ophthalmological screening. We analysed the risk of SLE flares after HCQ reduction or discontinuation after detection of early ophthalmological toxicity.

METHODS

This study includes all patients with SLE among the 109 included in the prospective PERFOCTAPS Study and treated with HCQ for at least 5 years. Patients were divided into 3 groups: HCQ maintenance, reduction and discontinuation after intensive ophthalmological screening. Flare occurrence (SELENA-SLEDAI Flare Index) was assessed for 2 years after HCQ reduction or discontinuation or after inclusion in the maintenance group.

RESULTS

This study included 85 patients (98% women, mean age 40.0 years, and mean durations of SLE and HCQ treatment 14.4±7.7 years and 12.9±7.2 years, respectively). The PERFOCTAPS Study identified ophthalmological abnormalities in 25 patients (29.4%); these led to dose reduction in 20 patients and discontinuation in 5. Flares occurred in 29 patients (34.1%): 17 (28.3%) in the maintenance group, 10 (50%) in the reduction group and 2 (40%) in the discontinuation group. After adjustment for potential confounders, HCQ reduction was independently associated with the risk of flare (adjusted HR 2.26; 95% CI 1.03 to 4.97). The same trend was observed in the discontinuation group, but was no longer statistically significant (adjusted HR 2.13; 95% CI 0.44 to 10.27).

CONCLUSION

In this prospective study, HCQ reduction due to early suspicion of retinal toxicity was associated with a statistically significantly increased risk of disease flare.

TRIAL REGISTRATION NUMBER

NCT02719002.

Knowledge, attitudes, and practices toward biologics among systemic lupus erythematosus patients: a cross-sectional study

Objective

This study aimed to investigate the knowledge, attitudes, and practices (KAP) toward biologics among systemic lupus erythematosus (SLE) patients.

Methods

A cross-sectional study was conducted at Nanjing Drum Tower Hospital from March 2023 to January 2024. Demographic information and KAP were obtained through the distribution of self-designed questionnaires.

Results

A total of 543 SLE patients participated in this study, with a mean age of 39.14 ± 13.08 years. The mean scores for knowledge, attitude, and practice were 6.08 ± 5.49 (possible range: 0-32), 33.14 ± 4.01 (possible range: 10-50), and 12.06 ± 3.95 (possible range: 6-30), respectively. Multivariate logistic regression analysis revealed that knowledge score (OR = 1.08, 95% CI: 1.019-1.144, p = 0.009), attitude score (OR = 1.476, 95% CI: 1.337-1.63, p < 0.001), average monthly income of 5,000-10,000 Yuan (OR = 2.129, 95% CI: 1.327-3.416, p = 0.002), and average monthly income of more than 10,000 Yuan (OR = 2.245, 95% CI: 1.184-4.260, p = 0.013) were independently associated with proactive practice. Structural equation modeling revealed significant direct effects of knowledge on attitude (β = 0.586, p < 0.001) and practice (β = 0.140, p = 0.041). Additionally, attitudes were found to directly influence practice (β = 0.628, p < 0.001).

Conclusion

SLE patients demonstrated inadequate knowledge, suboptimal attitudes, and passive practices regarding biologics. It is recommended that healthcare providers prioritize education and interventions aimed at enhancing knowledge, fostering positive attitudes, and promoting proactive practices regarding biologic therapies among SLE patients.

Diagnosis and activity prediction of SLE based on serum Raman spectroscopy combined with a two-branch Bayesian network

Objective

This study aims to examine the impact of systemic lupus erythematosus (SLE) on various organs and tissues throughout the body. SLE is a chronic autoimmune disease that, if left untreated, can lead to irreversible damage to these organs. In severe cases, it can even be life-threatening. It has been demonstrated that prompt diagnosis and treatment are crucial for improving patient outcomes. However, applying spectral data in the classification and activity assessment of SLE reveals a high degree of spectral overlap and significant challenges in feature extraction. Consequently, this paper presents a rapid and accurate method for disease diagnosis and activity assessment, which has significant clinical implications for achieving early diagnosis of the disease and improving patient prognosis.

Methods

In this study, a two-branch Bayesian network (DBayesNet) based on Raman spectroscopy was developed for the rapid identification of SLE. Serum Raman spectra samples were collected from 80 patients with SLE and 81 controls, including those with dry syndrome, undifferentiated connective tissue disease, aortitis, and healthy individuals. Following the pre-processing of the raw spectra, the serum Raman spectral data of SLE were classified using the deep learning model DBayes. DBayesNet is primarily composed of a two-branch structure, with features at different levels extracted by the Bayesian Convolution (BayConv) module, Attention module, and finally, feature fusion performed by Concate, which is performed by the Bayesian Linear Layer (BayLinear) output to obtain the result of the classification prediction.

Results

The two sets of Raman spectral data were measured in the spectral wave number interval from 500 to 2000 cm-1. The characteristic peaks of serum Raman spectra were observed to be primarily located at 1653 cm-1 (amide I), 1432 cm-1 (lipid), 1320 cm-1 (protein), 1246 cm-1 (amide III, proline), and 1048 cm-1 (glycogen). The following peaks were identified: 1653 cm-1 (amide), 1432 cm-1 (lipid), 1320 cm-1 (protein), 1246 cm-1 (amide III, proline), and 1048 cm-1 (glycogen). A comparison was made between the proposed DBayesNet classification model and traditional machine and deep learning algorithms, including KNN, SVM, RF, LDA, ANN, AlexNet, ResNet, LSTM, and ResNet. The results demonstrated that the DBayesNet model achieved an accuracy of 85.9%. The diagnostic performance of the model was evaluated using three metrics: precision (82.3%), sensitivity (91.6%), and specificity (80.0%). These values demonstrate the model's ability to accurately diagnose SLE patients. Additionally, the model's efficacy in classifying SLE disease activity was assessed.

Conclusion

This study demonstrates the feasibility of Raman spectroscopy combined with deep learning algorithms to differentiate between SLE and non-SLE. The model's potential for clinical applications and research value in early diagnosis and activity assessment of SLE is significant.

Prediction of Flares in Systemic Lupus Erythematosus During Post-Remission Follow-up

Purpose

Patients at high risk of SLE flares benefit from being identified before flares; this can be done by predictors of flares. This study aimed to explore the predictive factors and model of SLE flares after remission, providing basis for clinical decision-making.

Patients and Methods

SLE patients recruited at the Peking Union Medical College Hospital (PUMCH), were all registered in the Chinese SLE treatment and research (CSTAR) registry cohort and had experienced at least one remission before December 31, 2020. Demographic, clinical, and laboratory parameters were collected through CSTAR online registry. The predictive effects of variables were analyzed using a Cox proportional hazards model. A nomogram was formulated to predict flares.

Results

A total of 359 patients were included in the analysis, among which, 108 (30.1%) patients had at least one flare. Multivariate Cox regression model showed that younger age (hazard ratio [HR], 0.97; 95% CI, 0.95-0.99), positive anti-dsDNA at remission (HR, 1.64; 95% CI, 1.08-2.51), significantly low levels of C3 and C4 (HR, 2.09; 95% CI, 1.17-3.73) were independent risk factors associated with flares. A nomogram was established based on the multivariate analysis. The internal bootstrap resampling approach suggested the nomogram has a certain degree of discriminatory power with a C-index of 0.654 (95% CI, 0.601-0.707). The calibration plots also showed good consistency between the prediction and the observation.

Conclusion

This study highlights that SLE patients with significantly low levels of C3 and C4, younger age, and elevated anti-dsDNA levels may require closer monitoring and follow-up after remission. Identifying these predictors allows clinicians to better assess the risk of flare and tailor therapeutic strategies accordingly for more effective long-term management.

Disease-Modifying Antirheumatic Drug Therapy of Inflammatory Rheumatic Diseases in End-Stage Kidney Disease

BACKGROUND

Inflammatory rheumatic diseases regularly require the use of disease-modifying antirheumatic drugs (DMARDs). The use of DMARDs in patients with end-stage chronic kidney disease (CKD stage 5D) is particularly challenging due to the lack of systematic studies available for this patient population. This narrative review aimed to address the aspect of DMARD therapy in CKD 5D.

SUMMARY

The current article is a narrative review. References were sourced from the following databases: PubMed, Web of Science, Cochrane Library, and Scopus. The search period spanned from 1975 to 2024. There is a notable lack of systematic data on this topic. The available literature was reviewed to provide insights, despite the limited availability of comprehensive studies. Individuals with terminal kidney disease can presumably be safely treated with leflunomide, mycophenolic acid, sulfasalazine, azathioprine, belimumab, and anti-CD20. For all other substances, there are either significant restrictions, insufficient data, or inadequate experience.

KEY MESSAGES

Some conventional and biologic DMARDs are available for the management of inflammatory rheumatic diseases in CKD stage 5D. It is essential to consider the limitations on kidney function, as they can significantly affect the pharmacokinetics of medications. Consequently, slightly more frequent checkups are recommended when using the defined preparations.

Paraneoplastic systemic lupus erythematosus associated with dysgerminoma: a case report and literature review

Rheumatic paraneoplastic syndromes are rare and generally occur no longer than two years before diagnosis of the associated malignancy. Therefore, it can be an essential clue to occult malignancy. A healthy 18-year-old female with no underlying diseases was referred to the rheumatology clinic due to morning stiffness in her hands and a new rash on her fingers. Her labs showed a positive ANA, anti-double strand DNA antibody, anti-RNP, and anti-ribosomal P. Nine months after the diagnosis with SLE, the patient presented with elevated levels of lactate dehydrogenase. A total-body computed tomography scan revealed a solid mass in the pelvis. The pathological findings corresponded to a dysgerminoma tumor. Following surgical tumor removal and chemotherapy, the patient went into remission with both SLE and her oncology conditions, with no relapse of her lupus symptoms in a one-year follow-up. This case underscores the importance of considering malignancy in unexplained lupus symptoms, a crucial point for all physicians to be aware of. We identified 13 cases of paraneoplastic SLE in a literature review. In most cases, SLE is resolved after the tumor has been treated.

Hydroxychloroquine-induced pigmentation in rheumatic diseases: prevalence, clinical features and influencing factors

OBJECTIVE

To describe the clinical features of Chinese patients with HCQ-induced pigmentation and analyse the potential risk factors associated with HCQ-induced pigmentation.

METHODS

A cross-sectional study was conducted over a duration of 7 months, during which patients who had received HCQ treatment for >6 months were included. Data was collected through a structured questionnaire that encompassed demographic and geographic characteristics, information on HCQ and concomitant medication usage, sun exposure characteristics and hyperpigmentation-related characteristics. Univariate and multivariate analyses were employed to calculate the statistical association between HCQ-induced pigmentation and multiple variables.

RESULTS

Out of 316 patients, 83 (26.3%) patients presented hyperpigmentation during HCQ treatment. Hyperpigmentation was presented after a median duration of HCQ treatment of 12 months (interquartile range, 6.0-30.0 months) with a median cumulative dose of 108 g of HCQ (interquartile range, 36-288 g). The most frequently affected sites of pigmentation were the face (60.2%), lower limbs (36.1%) and hands (20.5%). There was a linear decrease in the incidence of pigmentation with increasing daily sun exposure time (P = 0.030). In the multivariate analysis, variables (cumulative HCQ dose and daily sun exposure time) were included in the final models. The results revealed an independent correlation between HCQ-induced pigmentation and daily sun exposure exceeding 1 h (OR: 0.431; 95% CI: 0.208-0.892; P = 0.023).

CONCLUSIONS

The occurrence of HCQ-induced pigmentation is not uncommon, with an incidence rate of 26.3%. Daily sun exposure time exhibited a protective effect against HCQ-induced pigmentation.

[Human papillomavirus and systemic lupus erythematosus: A systematic review]

BACKGROUND

Human papillomavirus (HPV) infections cause cancer of the cervix, vagina, vulva, anus, penis and upper respiratory tract. The prevention of HPV-induced cancers is a public health issue. Patients with systemic lupus are at increased risk of persistent HPV infection and cervical cancer due to treatment-induced immunosuppression. HPV vaccination and screening for precancerous lesions are two effective means of preventing cervical cancer. Despite the demonstrated safety and efficacy of the HPV vaccine, coverage of HPV vaccination in SLE adults remains low. Screening for cervical cancer is only carried out as recommended in one lupus patient in two. Catch-up HPV vaccination, therapeutic vaccination and vaginal self-sampling are innovative prevention strategies adapted to patients at risk of HPV-induced cancer.

CONCLUSIONS

Measures to prevent HPV-induced cancers are insufficiently implemented in patients managed for systemic lupus. Healthcare professionals and patients need to be made aware of the importance of HPV preventing vaccination.

Hydroxychloroquine in patients with systemic lupus erythematosus: how much is enough?

OBJECTIVE

To assess the daily and weight-adjusted dosages of hydroxychloroquine (HCQ) and the effects on long-term remission in the Lupus-Cruces cohort.

METHODS

Observational study of routine clinical care data. We selected inception patients treated with HCQ with at least 5 years of follow-up. Prolonged remission was achieved when patients fulfilled definitions of remission in systemic lupus erythematosus remission criteria in five consecutive yearly visits. The associations between the weight-adjusted dose of HCQ during 5 years and prolonged remission were analysed. We also investigated the associations between prednisone doses, immunosuppressives (IS) and other antimalarial use with HCQ doses.

RESULTS

150 inception patients fulfilled the inclusion criteria. The mean starting dose of HCQ was 206 mg/day. The mean weight-adjusted starting dose of HCQ was 3.1 mg/kg/day with no patients treated with doses ≥5 mg/kg/day. Treatment with HCQ was maintained during the whole 5-year follow-up time in 147 patients (98%). The mean dose of HCQ during the 5-year follow-up was 194.6 mg/day (2.9 mg/kg/day). 108 patients (72%) were in prolonged remission. The mean weight-adjusted dose of HCQ per patient did not differ between those who did and did not achieve prolonged remission (2.9 vs 3 mg/kg/day, p=0.5). The dose of prednisone per patient (mean 2.3 mg/day during the 5-year follow-up) did not differ according to the weight-adjusted dose of HCQ. The mean weight-adjusted HCQ dose during the whole follow-up was the same in patients treated or not with IS or with mepacrine.

CONCLUSIONS

With the use of HCQ at stable doses of 200 mg/day (or 3.0-3.5 mg/kg/day) as the background therapy in patients with systemic lupus erythematosus, the majority of patients achieved prolonged remission.

Treatment of thrombotic microangiopathy associated with systemic lupus erythematosus with low-dose rituximab as an induction agent and belimumab as a maintenance agent

INTRODUCTION

Thrombotic microangiopathy (TMA) is a serious complication that can occur in patients with systemic lupus erythematosus (SLE), and TMA adversely affects prognosis and increases mortality. The treatment of TMA often requires immunosuppressive agents, high-dose corticosteroids and plasma exchange (PEX). Both rituximab (RTX) and belimumab (BEL) target B cells. The combination of RTX and BEL has recently been used for refractory and severe organ involvement in systemic lupus erythematosus. However, the clinical outcome of patients with TMA and SLE treated with sequential therapy between RTX and BEL remains elusive.

CASE REPORTS

We reported 2 patients who were diagnosed with SLE with TMA and were administered a combination treatment of high-dose corticosteroids, immunoglobulin, and PEX at the initial stage. No improvements in microangiopathic anaemia, thrombocytopenia, or renal failure were observed. Low-dose RTX was administered in both patients, and both patients responded well. BEL was utilized to rapidly reduce the reliance on these agents and prevent the relapse of SLE at the maintenance stage. Ultimately, 2 patients fully recovered with an SLE Disease Activity Index score of 0, and prednisolone was stopped without relapse.

CONCLUSION

Sequential treatment with low-dose RTX and BEL could be an encouraging approach for the treatment of TMA in patients with SLE and rapid glucocorticoid reduction.

Delayed global standardization and prefectural disparities in systemic lupus erythematosus treatment in Japan: A nationwide study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan

OBJECTIVES

The aim of this study was to evaluate the status of the global standardization of, and prefectural differences in, systemic lupus erythematosus (SLE) treatments in Japan.

METHODS

The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan) was used. A patient with SLE was defined as having a disease with ICD-10 code M321 or M329 between April 2019 and March 2020, for which oral corticosteroids, immunosuppressive agents, or biologic agents were prescribed at least once during a given month. SLE treatments were evaluated by treatment centre type and prefecture.

RESULTS

In total, 74,277 patients met the definition of SLE. The SLE prevalence was 60 per 100,000 (range: 47-102 per 100,000 by prefecture). Nationwide, 79.4% of the patients (range: 52.1-93.3% by prefecture) visited a specialized treatment centre (STC); 37.4% (range: 26.4-51.3% by prefecture) received only oral corticosteroids, with fewer of these patients visiting an STC than a non-STC (34.8% and 49.7%, P < .001); and 21.4% (range: 10.7-35.0%) received hydroxychloroquine, with more of these patients visiting an STC than a non-STC (23.0% and 13.5%; P < .001).

CONCLUSIONS

The NDB Japan demonstrated the delayed global standardization of, and prefectural disparity in, SLE treatments in Japan.

Attribution of psychiatric manifestations to systemic lupus erythematosus in Chinese patients: A retrospective study

BACKGROUND

Not all neuropsychiatric (NP) manifestations in patients with systemic lupus erythematosus (SLE) are secondary to lupus. The clarification of the cause of NP symptoms influences therapeutic strategies for SLE.

AIM

To understand the attribution of psychiatric manifestations in a cohort of Chinese patients with SLE.

METHODS

This retrospective single-center study analyzed 160 inpatient medical records. Clinical diagnosis, which is considered the gold standard, was used to divide the subjects into a psychiatric SLE (PSLE) group (G1) and a secondary psychiatric symptoms group (G2). Clinical features were compared between these two groups. The sensitivity and specificity of the Italian attribution model were explored.

RESULTS

A total of 171 psychiatric syndromes were recorded in 138 patients, including 87 cases of acute confusional state, 40 cases of cognitive dysfunction, 18 cases of psychosis, and 13 cases each of depressive disorder and mania or hypomania. A total of 141 (82.5%) syndromes were attributed to SLE. In contrast to G2 patients, G1 patients had higher SLE Disease Activity Index-2000 scores (21 vs 12, P = 0.001), a lower prevalence of anti-beta-2-glycoprotein 1 antibodies (8.6% vs 25.9%, P = 0.036), and a higher prevalence of anti-ribosomal ribonucleoprotein particle (rRNP) antibodies (39.0% vs 22.2%, P = 0.045). The Italian attribution model exhibited a sensitivity of 95.0% and a specificity of 70.0% when the threshold value was set at 7.

CONCLUSION

Patients with PSLE exhibited increased disease activity. There is a correlation between PSLE and anti-rRNP antibodies. The Italian model effectively assesses multiple psychiatric manifestations in Chinese SLE patients who present with NP symptoms.

Real-World Effectiveness of Intravenous Belimumab on Clinical Outcomes in Patients With Systemic Lupus Erythematosus in Saudi Arabia: The OBSErve Observational Study

Purpose

To describe intravenous (IV) belimumab's clinical effectiveness in patients with systemic lupus erythematosus (SLE) in real-world practice in Saudi Arabia.

Patients and methods

This retrospective, observational OBSErve study (GSK Study 215349) analyzed medical record data for adults with SLE receiving IV belimumab. Index date was the date of belimumab initiation. The primary endpoint was overall clinical response per physician judgement (categorized as worse, no improvement, improvement of <20%, 20-49%, 50-79%, ≥80%) at 6 months post-index. The secondary endpoints included changes from index in Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI) score and corticosteroid dose at 6 months post-index; and healthcare resource utilization (HCRU) 6 months pre- and post-index.

Results

Of 47 patients enrolled, 44 patients completed ≥6 months of IV belimumab treatment and were included in the analysis. Most patients were female (91.5%) and the mean (standard deviation [SD]) age was 33.1 (8.1) years. At 6 months post-index, overall physician-assessed clinical improvements of ≥20% and ≥50% were reported for 97.7% (n=43) and 79.5% (n=35) of patients, respectively; 2.3% (n=1) of patients had no improvement, and no patient worsened. Mean SELENA-SLEDAI score decreased by 7.8 points during the 6 months post-index. Mean (SD) corticosteroid dose decreased from 10.2 (7.5) mg/day at index to 6.2 (3.4) mg/day at 6 months post-index. Reductions in unscheduled physician office and emergency room visits were observed during the post-index versus pre-index periods.

Conclusion

Real-world data from patients with SLE treated with IV belimumab in Saudi Arabia demonstrated clinical improvements and reductions in corticosteroid dose and HCRU. Although the low number of patients and lack of a control group limit interpretation, the similar findings to the other OBSErve studies support the effectiveness of belimumab for patients with SLE in Saudi Arabia.

Dual seropositive nonerosive lupus arthritis: rhupus or not?

BACKGROUND

There is no consensus on the classification of lupus arthritis (LA). In this study, we aimed to investigate patients with LA who were clinically and serologically very similar to those patients with rheumatoid arthritis (RA).

METHODS

The electronic medical files of systemic lupus erythematosus (SLE) patients from a single tertiary rheumatology department between 2017 and 2022 were reviewed. The inclusion criteria were being age ≥ 18 years, having nonerosive peripheral arthritis lasting longer than six months, and having dual seropositive (rheumatoid factor (RF) and anti-citrullinated protein antibody (anti-CCP)) serology. A nonerosive course of arthritis was demonstrated by both conventional radiography and joint ultrasound. Images were assessed by two blinded rheumatologists. Patients with drug-induced lupus and those with other rheumatologic diseases were excluded.

RESULTS

The cases of 528 patients were reviewed, and eight patients were included in the study. All patients were female, and the median age was 48.5 years. The median SLE and arthritis durations were 12 and seven years, respectively. The most common SLE symptom was photosensitivity (n = 8). Only one patient had life-threatening involvement (LTI), which was a seizure and autoimmune haemolytic anaemia. All patients had arthritis affecting the wrist and hand. Anti-dsDNA was the most common anti-ENA antibody (n = 7), followed by anti-SSA (n = 5). The median RF and anti-CCP titres were 82.5 IU/ml and 81.5 U/ml, respectively. Five patients had high titres of autoantibodies, and only one patient had slight hypocomplementemia. Three patients needed biologic agents, and remission was achieved after treatment with rituximab.

CONCLUSION

Despite a long arthritis duration and dual seropositive serology with high titres of RF and anti-CCP, our patients had SLE rather than rhupus syndrome. The low frequency of LTIs, such as lupus nephritis, was a remarkable feature of our patients. Lupus arthritis may be clinically and serologically indistinguishable from RA. Prospective studies are needed to better define LA.

The association between polypharmacy and disease control in rheumatoid arthritis and systemic lupus erythematosus: a cohort study

Polypharmacy can be associated with poor outcomes in chronic diseases. Our objective is to determine the prevalence of polypharmacy and its association with disease control in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). An observational study was conducted using the SARD database of the CHU de Québec. Participants newly diagnosed with RA or SLE enrolled in the database after 24 months were included. Collected data included number and type of medications, Charlson Comorbidity Index, and medication adherence (proportion of days covered during the first 180 days). Polypharmacy was defined as the simultaneous use ≥5 medications. Multivariable logistic and linear regressions were used to determine the association between polypharmacy and disease control (DAS28CRP, SLEDAI-2 K). The study included 111 participants (RA = 81; SLE = 30). Medication count increased at two years in RA (mean ± SD): 4.6 ± 3.3 to 6.9 ± 3.6; and SLE: 6.5 ± 4.6 to 7.80 ± 4.82. Polypharmacy prevalence increased at two years: RA: from 43 to 74%; SLE: from 47 to 73%. Mean medication adherence exceeded 85%. For RA participants, polypharmacy was associated with a better DAS28CRP score at one year [adjusted odds ratio of achieving a poor outcome: 0.17 (95%CI 0.04-0.71)], but this association was lost at two years [2.88 (0.45-18.29)]. For SLE, polypharmacy was not associated with disease activity based on the SLEDAI-2 K at one year [7.36 (0.26-211.16)] or two years [0.32 (0.05-1.99)]. Overall, polypharmacy is very prevalent in RA and SLE and could be positively associated with the level of disease control in the year after a diagnosis of RA.

Primary cutaneous Mycobacteria avium complex infection in a systemic lupus erythematosus patient: A case report and review

RATIONALE

Nontuberculous mycobacteria infection is becoming more and more common in clinical practice, while skin and soft tissue infection is an important part. The evaluation of the immune status of patients has certain reference value for diagnosis and treatment.

PATIENT CONCERNS

A 48-year-old woman developed an erythematosus nodule with purulent discharge on the right hip for 4 months. She had a history of systemic lupus erythematosus for more than 20 years, in stable control with prednisone 10 mg/d, azathioprine 50 mg/12 h, and hydroxychloroquine 200 mg/12 h. There was no trauma prior to the lesion.

DIAGNOSES

After excluding other sites involved, the patient was diagnosed as Mycobacterium avium primary cutaneous infection based on laboratory culture, biopsy, and sequencing techniques.

INTERVENTIONS

After surgical resection, a combination of oral azithromycin, rifampicin, and ethambutol hydrochloride was given.

OUTCOMES

The lesion healed after 4 months with no relapse.

LESSONS

Primary cutaneous nontuberculous mycobacteria infection should raise more attention in immunocompromised and even immunocompetent populations.

Endocrine and metabolic comorbidities in juvenile-onset systemic lupus erythematosus

Background and aims

Juvenile-onset systemic lupus erythematosus (JSLE) is a chronic autoimmune disease affecting individuals under 18, causing multi-system impairment. Patients with JSLE exhibit more severe disease when compared to patients with adult-onset SLE. This study aimed to evaluate the prevalence of endocrine and metabolic comorbidities in patients with JSLE, and analyze the factors associated with each comorbidity.

Methods

Anthropometric, clinical, laboratory data, and the details of glucocorticoids and disease-modifying anti-rheumatic drugs use were collected.

Results

A total of 57 patients with JSLE (48 girls and 9 boys) were included in this study. Endocrine and metabolic comorbidities were observed in 64.9% of the patients. The most prevalent comorbidities were dyslipidemia (40.4%), being overweight or obese (26.3%), subclinical hypothyroidism (24.6%), autoimmune thyroid disease (AITD) (21.1%), and low bone mass (20.9%). The risk of dyslipidemia and AITD increased in patients who were overweight or obese. The risk of being overweight or obese was associated with skin involvement at diagnosis and rheumatoid factor positivity. Younger age at diagnosis and longer duration of glucocorticoid exposure increased the risk of low bone mass. The overall prevalence of endocrine and metabolic comorbidities was associated with short stature at diagnosis, being overweight or obese at follow-up, skin involvement at diagnosis, and rheumatoid factor positivity.

Conclusion

Patients with JSLE have higher burdens of endocrine and metabolic comorbidities and should be routinely monitored. Prevention of obesity may be helpful in lowering the risk of comorbidities.

The Etiology of Intracranial Artery Stenosis in Autoimmune Rheumatic Diseases: An Observational High-Resolution MR Imaging Study

BACKGROUND AND PURPOSE

Autoimmune rheumatic diseases (AIRD) can cause intracranial artery stenosis (ICAS) and lead to stroke. This study aimed to characterize patients with ICAS associated with AIRD.

MATERIALS AND METHODS

Using data from a high-resolution MR imaging database, we retrospectively reviewed patients with AIRD with ICAS. Stratification into vasculitis, atherosclerosis, and mixed atherovasculitis subtypes was based on imaging findings, followed by a comparative analysis of clinical characteristics and outcomes across these subgroups.

RESULTS

Among 139 patients (mean, 45.1 [SD, 17.3] years; 64.7% women), 56 (40.3%) were identified with vasculitis; 57 (41.0%), with atherosclerosis; and 26 (18.7%), with mixed atherovasculitis. The average interval from AIRD onset to high-resolution MRI was 5 years. Patients with vasculitis presented at a younger age of AIRD onset (mean, 34.5 [SD, 19.4] years), nearly 10 years earlier than other groups (P = .010), with a higher artery occlusion incidence (44.6% versus 21.1% and 26.9%, P = .021). Patients with atherosclerosis showed the highest cardiovascular risk factor prevalence (73.7% versus 48.2% and 61.5%, P = .021) but fewer intracranial artery wall enhancement instances (63.2% versus 100% in others, P < .001). The mixed atherovasculitis group, predominantly men (69.2% versus 30.4% and 24.6%, P < .001), exhibited the most arterial involvement (5 arteries per person versus 3 and 2, P = .001). Over an average 21-month follow-up, 23 (17.0%) patients experienced stroke events and 8 (5.9%) died, with the mixed atherovasculitis group facing the highest risk of stroke events (32.0%) and the highest mortality (12.0%).

CONCLUSIONS

Intracranial arteries are injured and lead to heterogeneous disease courses when exposed to AIRD and cardiovascular risk factors. While atherosclerosis acceleration is common, vasculitis may further contribute to the early development of occlusion and multiple artery involvement. Varied intracranial arteriopathies may result in different outcomes.

Infective endocarditis causing acute aortic occlusion in a patient with systemic lupus erythematosus: A rare case report

INTRODUCTION

We present a unique case of acute aortic occlusion secondary to infective endocarditis (IE).

PRESENTATION OF CASE

An Aboriginal Australian woman with systemic lupus erythematosus presented with fever, confusion, tachycardia, and tachypnoea and had cold, pulseless, insensate, and paralysed lower limbs. Computed tomography angiography revealed multifocal occlusion of the distal aorta and lower limb vessels. Broad-spectrum antibiotic therapy was initiated alongside heparin infusion, and thrombectomy and four-compartment fasciotomy of the lower limbs were performed. IE, thrombotic thrombocytopenic purpura, and antiphospholipid syndrome were considered. IE was confirmed by the presence of methicillin-susceptible Staphylococcus aureus in blood cultures and new valvular echogenic lesions on echocardiography. Magnetic resonance imaging revealed diffused T9-T11 spinal cord infarcts. She received a prolonged course of intravenous antibiotics and intensive care and was hospitalised for 9 months. Thereafter, the patient was able to transfer and ambulate independently on flat surfaces and was discharged.

DISCUSSION

IE is associated with significant mortality and morbidity. It is commonly caused by S. aureus. Embolic events occur in 80 % of patients. Acute aortic occlusion secondary to IE has rarely been reported in the literature, and this is the first reported case involving the bilateral lower limbs.

CONCLUSION

Patients may develop severe infections owing to immunosuppression. Septic emboli can occlude major arteries and cause acute limb ischaemia. A good understanding of the pathophysiology and aetiology of systemic thrombosis will lead to a thorough and broad consideration of differential diagnoses, especially for patients with complex comorbidities and a history of rheumatological disease and immunosuppression.

Disease features at diagnosis and changes in disease course severity among commercially insured patients with childhood-onset compared with adult-onset systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) causes widespread inflammation and damage in affected organs. Severity is determined by the type of organ systems affected and the extent of involvement. SLE occurs in childhood or adulthood and disease severity varies according to age of onset. We compared disease features and changes in disease severity over time between childhood-onset (cSLE) and adult-onset SLE (aSLE).

METHODS

Patients 0-64 years old, newly diagnosed with SLE during 2014-2020 were identified using the MarketScan® database. A validated algorithm was used to assess disease severity. Improving severity versus baseline was defined as a transition from a higher (severe) to a lower (mild/moderate) disease state during each evaluation period. Group comparisons were made using the Pearson chi-square test for categorical and t test for continuous measures.

RESULTS

A total of 10,912 patients were included. Most (89.9%) were female with a mean age of 14.2 versus 44.6 years for cSLE and aSLE groups, respectively. Patients with cSLE were more likely to have severe disease at diagnosis (38.3% vs 10.7%; p < .0001) versus aSLE. The largest reduction in SLE severity occurred during 6 to <12 months post-index with cSLE experiencing the greatest improvement (36.7% vs 19.9%; p < .0001) compared with aSLE. However, despite improvements observed over time in cSLE, this group was still more likely to have severe disease at 0 to <6 months (26.4% vs 10.5%) and 6 to <12 months (14.4% vs 8.6%) post-index compared with aSLE patients (p < .01, all). For aSLE, the proportions of patients experiencing either an improvement or deterioration in symptoms was similar during 0 to <6 months and 6 to <12 months. However, during 12 to <24 months, nearly twice as many patients in this group experienced a deterioration in symptoms (30.1%) compared to improvement (15.6%).

CONCLUSIONS

Children with SLE present with greater symptom severity compared with adults. Although children were more likely to experience improvements following treatment, they had more active disease over time than aSLE patients. Disease severity remained stable for aSLE patients until the second year of follow-up, when more patients experienced a deterioration rather than improvement in symptoms.

Association of disease activity with depression and anxiety in systemic lupus erythematosus: a comparison of SLEDAI-2K and SLE-DAS

OBJECTIVE

To explore the association of disease activity, as evaluated by both the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) and the SLEDAI-2000 (SLEDAI-2K), with depression and anxiety in patients with SLE.

METHODS

A cross-sectional study was conducted among 85 Chinese patients with SLE. Disease activity was measured using SLEDAI-2K and SLE-DAS scoring systems. Depression and anxiety were assessed using Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7, respectively. Multivariate logistic regression analysis was performed to evaluate the association of disease activity scores, as well as specific clinical and laboratory items, with depression and anxiety.

RESULTS

There was a robust correlation between SLEDAI-2K and SLE-DAS scores in overall patient population (Spearman's r = 0.764, 95% CI 0.655-0.842; P < 0.001) and in those with moderate-to-high disease activity (Spearman's r = 0.792, 95% CI 0.616-0.892; P < 0.0001). However, the correlation weakened for patients with mild disease activity or remission (Spearman's r = 0.450, 95%CI 0.188-0.652; P = 0.001). Multivariate logistic regression analysis did not show a significant correlation between SLEDAI-2K and SLE-DAS scores and depression/anxiety. The presence of mucosal ulcer/serositis significantly increased the risk of depression (odds ratio = 4.472, 95% CI 1.035-19.328; P = 0.045) and anxiety (odds ratio = 3.978, 95% CI 1.051-15.049; P = 0.042).

CONCLUSION

The SLE-DAS scoring system demonstrated a comparable ability to assess disease activity in SLE compared with SLEDAI-2K. Though neither scoring system showed significant associations with depression and anxiety, the presence of mucosal ulcer/serositis markedly heightened the risk of both among SLE patients.

Evaluation and prediction of relapse risk in stable systemic lupus erythematosus patients after glucocorticoid withdrawal (PRESS): an open-label, multicentre, non-inferiority, randomised controlled study in China

OBJECTIVES

To explore the relapse rate after glucocorticoid (GC) withdrawal with or without hydroxychloroquine (HCQ) maintenance in sustained clinically inactive systemic lupus erythematosus (SLE).

METHODS

The PRESS trial is a multicentre, 33-week, open-label, three-arm, non-inferiority designed, randomised controlled trial. SLE patients with sustained clinically inactive disease who maintained on low-dose GC plus HCQ therapy were screened and qualified patients were randomly assigned to three groups: drug-free group (both GC and HCQ withdrew); HCQ group (discontinued GC but maintained HCQ); dual maintenance group (both GC and HCQ continued). The primary endpoint was to compare the proportion of patients experiencing a relapse as defined by the Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index flare index by 33 weeks. Two parallel non-inferiority analyses were performed (drug-free group vs dual maintenance group and HCQ group vs dual maintenance group).

RESULTS

From 3 November 2016 to 13 August 2021, 333 participants complied with the protocol after randomisation were analysed. The relapse rates in the three groups were 26.1%, 11.2% and 4.7%, respectively. Compared with dual maintenance group, drug-free group failed to achieve non-inferiority significance (relapse rate difference 21.4%; 95% CI 12.3% to 30.5%; Pnon-inferiority=0.238), whereas HCQ group achieved non-inferiority (relapse rate difference 6.5%; 95% CI -0.5% to 13.5%; Pnon-inferiority=0.034). HCQ group also exhibited fewer relapses than drug-free group (p=0.006). Adverse events were similar among all three groups.

CONCLUSIONS

GC withdrawal may be feasible in sustained clinically inactive SLE patients. HCQ maintenance can exert a protective role in preventing disease relapse after GC withdrawal. Trial registration number NCT02842814.

The effectiveness of telitacicept in patients with systemic lupus erythematosus: A retrospective, real-world study

OBJECTIVE

Despite some study demonstrated the effectiveness of telitacicept in patients with systemic lupus erythematosus (SLE), a noticeable gap exists in real-world data. This study aimed to examine the effectiveness and safety of telitacicept in patients with SLE in the real-world.

METHOD

This retrospective study enrolled patients with SLE at the Tangdu Hospital from January 2022 to January 2023. These patients were administered telitacicept at 80 mg or 160 mg dosage. The observed outcomes were changes in the SLE Responder Index 4 (SRI-4), disease activity, renal function, and immunological indicators.

RESULT

Sixty-one patients were enrolled, with 60 patients completed the 24-week follow-up, and 30 completed the 52-week. The SRI-4 response rates at 4, 12, 24, and 52 weeks were 52.5%, 67.2%, 75.4%, and 80.0%, respectively. No statistically differences were observed in the SRI-4 response rates between the 80 mg and 160 mg doses at any of the time points (all p > 0.05). By 52 weeks, the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index scores were significant decreased from baseline (p < 0.001), and complement 3 and 4 levels (p = 0.001), albumin levels (p = 0.004), and the overall change in glucocorticoid dosage (p < 0.001) were all significantly increased, with all showing significant changes over time (p < 0.001). During the study, 3 (4.9%) patients experienced infection, and 1 (1.6%) developed an allergy at the injection site.

CONCLUSION

Telitacicept exhibited a highly effective and favorable safety in patients with SLE, with improved renal and hematological manifestations and facilitated a reduction in glucocorticoid medication usage.

A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions

PURPOSE

Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions.

METHODS

A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted.

RESULTS

The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials.

CONCLUSION

This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.

Healthcare costs of systemic lupus erythematosus in New Zealand

OBJECTIVES

This study aims to estimate the annual medical costs of systemic lupus erythematosus (SLE) in New Zealand (NZ).

METHODS

SLE patients were linked to the Australia and New Zealand Dialysis and Transplant Registry, Pharmaceutical Collection, National Minimum Dataset, National Non-Admitted Patients Collection and Mortality Collection. National direct medical costs of SLE in 2006-2021 and annual costs per patient were estimated. Generalized linear model was used to examine the impact of various factors on medical costs, including ethnicity, gender, age, socioeconomic status and presence of end-stage kidney disease (ESKD).

RESULTS

The annual national costs of SLE were stable over time, around NZ$12 million. The average costs were NZ$8,324 (US$5,277, €5,011) per patient per year, with the costs for patients with ESKD being nine times higher than patients without ESKD (NZ$47,143 vs NZ$5,091). The costs per patient for Māori and Pacific were both around twice the costs for European/Others (NZ$13,124 and NZ$11,842 vs NZ$6,153), but the difference attenuated after adjustment for ESKD and other factors. Among patients without ESKD, Asian, males and patients living in the most deprived areas were associated with higher costs. For patients with ESKD, Māori and patients living in the most deprived areas had higher costs.

CONCLUSIONS

The annual national costs of SLE were stable over time. The increase in pharmaceutical costs were offset by decrease in hospitalisation costs. Costs for patients with ESKD were nine times higher than costs for patients without ESKD. Interventions for slowing the disease progression and preventing ESKD can reduce medical costs.

Serious infections and tuberculosis adversely impact outcomes of juvenile onset systemic lupus erythematosus in India

BACKGROUND

Infections are a major cause of morbidity and mortality in juvenile systemic lupus erythematosus (SLE). We assessed the incidence and risk factors for major infections in juvenile SLE.

METHODS

A retrospective review of 225 patients of juvenile SLE (ACR 1997 criteria) with age <18 years visiting the rheumatology clinic at a single centre between 2000 to 2020 was done from case records and the hospital electronic health records. Serious infection was defined as the need for hospitalization, or infection resulting in disability or death. Cox regression was used to determine factors associated with a serious infection and the effect of serious infection on overall survival.

RESULTS

We reviewed 225 children (197 girls, mean age 13.89 ± 3.42 years) with a cumulative follow up of 1153.45 person-years. Eighty serious infections occurred in 63 (28% of the cohort) children at a rate of 69.35 serious infections per 1000 person-years. A second serious infection occurred in 12 children and 5 of them developed three infections.Among the cases with known etiology (78.75% of cases), bacterial infections were most common (N = 33) including S. Aureus (11), E. Coli (7), K. Pneumoniae (3), E. Fecalis (3), S. Pneumoniae (2), Acinetobacter spp. (2), Citrobacter (2), Salmonella (2) and P. Aeruginosa (1). Twenty six (32.5%) opportunistic infections occurred: Mycobacterium tuberculosis (18), Cytomegalovirus (3), disseminated Herpes zoster (4) and invasive candidiasis (1) with 15 (83.3%) of the tuberculosis cases being extrapulmonary. On multivariate analysis, fever (HR 8.51, 1.17-61.44), gastrointestinal involvement (HR 4.73, 1.13-19.94), current steroid dose (HR 1.36,1.14-1.62), average cumulative steroid dose per year (HR 1.004, 1.002-1.005) and cyclophosphamide (HR 2.22, 1.11-4.46) were associated with serious infection.Hospitalization rates were significantly higher in those with any serious infection (Rate-ratio 2.79, 1.81-3.77) as was damage accrual (SLICC damage index 1.04 vs 0.22). Serious infection-free survival at 1 year and 5 years was 84% (79.1-89.2) and 72% (65.4-79.2). There were 19 deaths with infection attributable mortality in 10 (52.6%). Serious infection predisposed to higher overall mortality with recurrent infections conferring a hazard ratio of 36.02 (8.07-160.62).

CONCLUSION

Serious infections are a major cause of mortality and damage in SLE. Constitutional symptoms, gastrointestinal involvement, current and cumulative steroid dose and cyclophosphamide predict serious infections. TB prophylaxis in patients with SLE should be considered in endemic areas, especially when using high-dose steroid therapy.

Pharmacological Mechanism of Chinese Medicine in Systemic Lupus Erythematosus: A Narrative Review

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder affecting multiple systems, characterized by the development of harmful autoantibodies and immune complexes that lead to damage in organs and tissues. Chinese medicine (CM) plays a role in mitigating complications, enhancing treatment effectiveness, and reducing toxicity of concurrent medications, and ensuring a safe pregnancy. However, CM mainly solves the disease comprehensively through multi-target and multi-channel regulation process, therefore, its treatment mechanism is often complicated, involving many molecular links. This review introduces the research progress of pathogenesis of SLE from the aspects of genetics, epigenetics, innate immunity and acquired immunity, and then discusses the molecular mechanism and target of single Chinese herbal medicine and prescription that are commonly used and effective in clinic to treat SLE.