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任 立, 赵 楚, 赵 义, 周 惠, 张 莉, 王 友, 沈 凌, 范 文, 李 洋, 厉 小, 王 吉, 程 永, 彭 嘉, 赵 晓, 邵 苗, 李 茹. [Low disease activity and remission status of systemic lupus erythematosus in a real-world study]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2024; 56:273-278. [PMID: 38595244 PMCID: PMC11004968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To investigate the rates of low disease activity and clinical remission in patients with systemic lupus erythematosus (SLE) in a real-world setting, and to analyze the related factors of low disease activity and clinical remission. METHODS One thousand patients with SLE were enrolled from 11 teaching hospitals. Demographic, clinical and laboratory data, as well as treatment regimes were collec-ted by self-completed questionnaire. The rates of low disease activity and remission were calculated based on the lupus low disease activity state (LLDAS) and definitions of remission in SLE (DORIS). Charac-teristics of patients with LLDAS and DORIS were analyzed. Multivariate Logistic regression analysis was used to evaluate the related factors of LLDAS and DORIS remission. RESULTS 20.7% of patients met the criteria of LLDAS, while 10.4% of patients achieved remission defined by DORIS. Patients who met LLDAS or DORIS remission had significantly higher proportion of patients with high income and longer disease duration, compared with non-remission group. Moreover, the rates of anemia, creatinine elevation, increased erythrocyte sedimentation rate (ESR) and hypoalbuminemia was significantly lower in the LLDAS or DORIS group than in the non-remission group. Patients who received hydroxychloroquine for more than 12 months or immunosuppressant therapy for no less than 6 months earned higher rates of LLDAS and DORIS remission. The results of Logistic regression analysis showed that increased ESR, positive anti-dsDNA antibodies, low level of complement (C3 and C4), proteinuria, low household income were negatively related with LLDAS and DORIS remission. However, hydroxychloroquine usage for longer than 12 months were positively related with LLDAS and DORIS remission. CONCLUSION LLDAS and DORIS remission of SLE patients remain to be improved. Treatment-to-target strategy and standar-dized application of hydroxychloroquine and immunosuppressants in SLE are recommended.
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Affiliation(s)
- 立敏 任
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 楚楚 赵
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 义 赵
- 首都医科大学宣武医院风湿免疫科,北京 100053Department of Rheumatology and Immunology, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - 惠琼 周
- 解放军总医院第四医学中心风湿免疫科,北京 100142Department of Rheumatology, the Fourth Medical Center of PLA General Hospital, Beijing 100142, China
| | - 莉芸 张
- 山西大医院风湿免疫科,太原 030032Department of Rheumatology, Shanxi Dayi Hospital, Taiyuan 030032, China
| | - 友莲 王
- 江西省人民医院风湿免疫科,南昌 330006Department of Rheumatology, Jiangxi Provincial People's Hospital, Nanchang 330006, China
| | - 凌汛 沈
- 华中科技大学协和医院风湿免疫科,武汉 430022Department of Immunology and Rheumatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - 文强 范
- 新乡医学院附属中心医院风湿免疫科,河南新乡 453099Department of Rheumatology and Immunology, The Fourth Clinical College of Xinxiang Medical University, Xinxiang 453099, Henan, China
| | - 洋 李
- 哈尔滨医科大学附属第二医院风湿免疫科,哈尔滨 150001Department of Rheumatology and Immunology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - 小梅 厉
- 安徽省立医院风湿免疫科,合肥 230001Department of Rheumatology and Immunology, Anhui Provincial Hospital, Hefei 230001, China
| | - 吉波 王
- 青岛大学附属医院风湿免疫科,山东青岛 266000Department of Rheumatology, The Affliated Hospital of Qingdao University, Qingdao 266000, Shandong, China
| | - 永静 程
- 北京医院风湿免疫科,北京 100730Department of Rheumatology and Immunology, Beijing Hospital, Beijing 100730, China
| | - 嘉婧 彭
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 晓珍 赵
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 苗 邵
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
| | - 茹 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing 100044, China
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Alenzi F, Ateka-Barrutia O, Ken Cheah C, Khamashta M, Sangle SR, D’Cruz DP. Lupus Nephritis Outcomes after Stopping Immunosuppression. J Clin Med 2024; 13:2211. [PMID: 38673484 PMCID: PMC11051179 DOI: 10.3390/jcm13082211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Immunosuppression (IS) is a standard therapy for lupus nephritis (LN). Data on the outcomes of patients with LN after the discontinuation of immunosuppression remain uncertain. This study aimed to evaluate the outcomes and results of patients with lupus nephritis (LN) who ceased immunosuppressive (IS) therapy. Methods: Records were obtained on the clinical and laboratory features of LN patients who were treated at our Lupus Unit. They included median values and ranges for various numerical variables such as patient age, disease duration, and treatment duration. Categorical variables such as gender, LN class, IS treatment type, and patient outcomes, which were categorized as either "stable" or "flare experienced", were presented as percentages and frequencies. A flare in LN was characterized by a two-fold increase in serum creatinine levels and a rise in proteinuria following the cessation of IS medication. Results: Outcomes were assessed for 45 patients with LN who ceased IS therapy after achieving remission. The patients' median age was 55 years (29-78). The median duration of treatment was 4 years (0.5-14). The LN histology distribution was class V = 24.4%, class IV = 17.8 %, class III = 17.8%, class III + IV = 15.6%, class III + V = 6.7%, class IV + V = 2.2%, and class II + IV and II = 2.2%. At the discontinuation of IS treatment, creatinine levels were elevated in 9/45 (20%) patients. Furthermore, 28.9% of patients relapsed after IS treatment discontinuation. Patients with anti-Smith antibodies (anti-Sm) were observed to have a higher occurrence of relapses, with six patients experiencing flare compared to four patients who remained stable (p = 0.03). Five (38.5%) of the patients with flares had high creatinine levels after IS discontinuation. Conclusions: Most of our patients maintained clinical remission and stable levels of LN parameters after IS treatment discontinuation. Those with a high serum creatinine level, ongoing proteinuria, depleted complement levels, and the presence of anti-Sm antibodies were more likely to experience flares after the discontinuation of IS therapy.
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Affiliation(s)
- Fahidah Alenzi
- Internal Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Oier Ateka-Barrutia
- Internal Medicine Department, Donostia University Hospital, 20014 Donostia, Spain;
| | - Chee Ken Cheah
- Louise Coote Lupus Unit, Counting House, Guy’s Hospital, Guy’s and St. Thomas’ Hospitals, NHS Foundation Trust, London SE1 9RT, UK; (C.K.C.); (M.K.); (S.R.S.); (D.P.D.)
| | - Munther Khamashta
- Louise Coote Lupus Unit, Counting House, Guy’s Hospital, Guy’s and St. Thomas’ Hospitals, NHS Foundation Trust, London SE1 9RT, UK; (C.K.C.); (M.K.); (S.R.S.); (D.P.D.)
| | - Shirish R. Sangle
- Louise Coote Lupus Unit, Counting House, Guy’s Hospital, Guy’s and St. Thomas’ Hospitals, NHS Foundation Trust, London SE1 9RT, UK; (C.K.C.); (M.K.); (S.R.S.); (D.P.D.)
| | - David P. D’Cruz
- Louise Coote Lupus Unit, Counting House, Guy’s Hospital, Guy’s and St. Thomas’ Hospitals, NHS Foundation Trust, London SE1 9RT, UK; (C.K.C.); (M.K.); (S.R.S.); (D.P.D.)
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Katsumata Y, Inoue E, Harigai M, Cho J, Louthrenoo W, Hoi A, Golder V, Lau CS, Lateef A, Chen YH, Luo SF, Wu YJJ, Hamijoyo L, Li Z, Sockalingam S, Navarra S, Zamora L, Hao Y, Zhang Z, Chan M, Oon S, Ng K, Kikuchi J, Takeuchi T, Goldblatt F, O'Neill S, Tugnet N, Law AHN, Bae SC, Tanaka Y, Ohkubo N, Kumar S, Kandane-Rathnayake R, Nikpour M, Morand EF. Risk of flare and damage accrual after tapering glucocorticoids in modified serologically active clinically quiescent patients with systemic lupus erythematosus: a multinational observational cohort study. Ann Rheum Dis 2024:ard-2023-225369. [PMID: 38423757 DOI: 10.1136/ard-2023-225369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES To assess the risk of flare and damage accrual after tapering glucocorticoids (GCs) in modified serologically active clinically quiescent (mSACQ) patients with systemic lupus erythematosus (SLE). METHODS Data from a 12-country longitudinal SLE cohort, collected prospectively between 2013 and 2020, were analysed. SLE patients with mSACQ defined as the state with serological activity (increased anti-dsDNA and/or hypocomplementemia) but without clinical activity, treated with ≤7.5 mg/day of prednisolone-equivalent GCs and not-considering duration, were studied. The risk of subsequent flare or damage accrual per 1 mg decrease of prednisolone was assessed using Cox proportional hazard models while adjusting for confounders. Observation periods were 2 years and censored if each event occurred. RESULTS Data from 1850 mSACQ patients were analysed: 742, 271 and 180 patients experienced overall flare, severe flare and damage accrual, respectively. Tapering GCs by 1 mg/day of prednisolone was not associated with increased risk of overall or severe flare: adjusted HRs 1.02 (95% CI, 0.99 to 1.05) and 0.98 (95% CI, 0.96 to 1.004), respectively. Antimalarial use was associated with decreased flare risk. Tapering GCs was associated with decreased risk of damage accrual (adjusted HR 0.96, 95% CI, 0.93 to 0.99) in the patients whose initial prednisolone dosages were >5 mg/day. CONCLUSIONS In mSACQ patients, tapering GCs was not associated with increased flare risk. Antimalarial use was associated with decreased flare risk. Tapering GCs protected mSACQ patients treated with >5 mg/day of prednisolone against damage accrual. These findings suggest that cautious GC tapering is feasible and can reduce GC use in mSACQ patients.
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Affiliation(s)
- Yasuhiro Katsumata
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eisuke Inoue
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Jiacai Cho
- National University Hospital of Singapore, Singapore
| | | | - Alberta Hoi
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | | | | | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shue-Fen Luo
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Kuei Shan, Taiwan
| | - Yeong-Jian Jan Wu
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Laniyati Hamijoyo
- Rheumatology Division, Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Sargunan Sockalingam
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Sandra Navarra
- University of Santo Tomas Hospital, Manila, The Philippines
| | - Leonid Zamora
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, The Philippines
| | - Yanjie Hao
- University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Zhuoli Zhang
- Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | | | - Shereen Oon
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Kristine Ng
- Waitemata District Health Board, Auckland, New Zealand
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University, Saitama, Japan
| | - Fiona Goldblatt
- Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Sean O'Neill
- University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | | | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea (the Republic of)
- Hanyang University Institute for Rheumatology Research, Seoul, Korea (the Republic of)
- Hanyang Institute of Bioscience and Biotechnology, Seoul, Korea (the Republic of)
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Naoaki Ohkubo
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Mandana Nikpour
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
- The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Mathian A, Arnaud L, Ruiz-Irastorza G. Is it safe to withdraw low-dose glucocorticoids in SLE patients in remission? Autoimmun Rev 2024; 23:103446. [PMID: 37683819 DOI: 10.1016/j.autrev.2023.103446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/10/2023]
Abstract
Glucocorticoids (GCs) remain a cornerstone of the treatment of Systemic Lupus Erythematosus (SLE). Numerous studies have emphasized the risk of damage accrual in SLE patient treated with GC, but currently, it is not possible to dissociate favorable and undesirable effects of GCs because their underlying mechanisms are entangled at the molecular level. Here, we review whether available data suggest that it is possible, feasible and desirable to taper and discontinue GC treatment in SLE. The main potential concern with GC withdrawal is the risk of SLE flare, which is strongly associated with increased organ damage, mortality, healthcare costs, decreased quality of life and work productivity. While most studies have assumed the cut off point for low doses (e.g. 7.5/mg/d) as the limit for safety, it is still controversial whether lower doses may influence damage accrual long-term. Also, a recent randomized trial has shown that a daily dose of 5 mg of prednisone in SLE patients in short-term remission can prevent up to 50-75% of flares, with an acceptable safety profile. However, this treatment is not mandatory for all patients. Yet, several observational studies highlight that discontinuation of GC is associated with lower damage accrual. Currently, we do not have a reliable method to identify patients who may require long-term low-dose GC. Therefore, further research is needed to identify a subgroup at high risk of relapse who would benefit from continuing prednisone. In the meantime, when considering the discontinuation of very low-dose prednisone, the decision must be individualized, as HCQ and conventional immunosuppressive agents are not without risk of side effects.
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Affiliation(s)
- Alexis Mathian
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière, Service de Médecine Interne 2, Institut E3M, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Laurent Arnaud
- Service de rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Centre National de Référence des maladies auto-immunes et systémiques rares Est/Sud-Ouest (RESO), Strasbourg, France.
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute. Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bizkaia, Spain
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Paredes-Ruiz D, Ruiz-Irastorza G, Amoura Z. Systemic lupus erythematosus and glucocorticoids: A never-ending story? Best Pract Res Clin Rheumatol 2023:101873. [PMID: 37957076 DOI: 10.1016/j.berh.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 11/15/2023]
Abstract
Glucocorticoids (GCs) continue to be essential agents for the management of systemic lupus erythematosus, since there are no other drugs able to active remission of active disease so rapidly. However, their potential for causing irreversible damage greatly limit their use. Fortunately, some strategies may help take advantage of their huge anti-inflammatory power while limiting GC-induced side effects. This article reviews the pharmacological basis of GC action and their translation into the clinical ground. We also offer the practical approach for the use of GC in induction and maintenance therapy as well as the strategies for GC withdrawal of the respective practice of the authors. The three main basic principles are a) using methyl-prednisolone pulses to induce remission not only in severe disease; b) limiting initial doses of prednisone to ≤30 mg/d, with rapid tapering to ≤5 mg/d, which should be the dose for maintenance therapy; and c) individualizing the decision and the strategy to withdraw GCs. Long-term therapy with HCQ and the early introduction of immunosuppressive treatment would help achieve these objectives.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bizkaia, Spain.
| | - Zahir Amoura
- Sorbonne Université, Faculté de Médecine, Groupement Hospitalier Pitié Salpêtrière, Centre National de Référence du Lupus Systémique, du Syndrome des Antiphospholipides et autres maladies auto-immunes, Service de Médecine Interne 2, Institut E3M, CIMI-Paris, Paris, France
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Monte TCS, Mateo PF, Izquierdo MG, Cervera R, López N, Pallares L, Torres MJÁ, Ortega SP. An online survey of the Spanish Lupus Patient Association (FELUPUS): patient perceptions and experiences. Clin Rheumatol 2023; 42:1259-1265. [PMID: 36627527 PMCID: PMC9838362 DOI: 10.1007/s10067-023-06500-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/23/2022] [Accepted: 12/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES A survey conducted by the Spanish Lupus Federation (FELUPUS) shows the results on perceptions and experiences of the people who live with lupus in Spain. The information was gathered anonymously from May 21st to June 30th, 2020. The aim of the study was to monitor the impact of the disease on quality of life, as well as to measure the impact of organ damage in lupus patients. METHODS A national survey was conducted among people with lupus living in Spain who belong to the Spanish Lupus Patient Association (FELUPUS). Online interviews of approximately 25 min were completed. The information was gathered anonymously from May 21st to June 30th, 2020. RESULTS One thousand two hundred sixty-three interviews were completed. 92% had a diagnosis of Systemic Lupus Erythematosus (SLE) and 8% of Cutaneous Lupus Erythematosus (CLE); 95% of the patients surveyed were female. Most of the patients claimed they stay up late, exercising and work/study were the most limited actions due to the disease. 73% of patients considered that there was little knowledge of the disease by society and at the time of diagnosis, the patient's level of knowledge about lupus was low in 92% of them. Regarding organ damage, many patients did not understand the concept of chronicity and irreversibility of the term, relating it erroneously to acute symptoms like fatigue (38%), joint pain (47%) and even to the presence of cutaneous symptoms such as the presence of oral ulcers (17%). CONCLUSIONS The survey highlighted the need for disease awareness campaigns, greater involvement of healthcare professionals and the need to provide more information to lupus patients from the time of diagnosis. Nationally and to our knowledge, this is the survey with the largest number of participants (N = 1263) conducted in patients with lupus. Key Points •A national survey was conducted among people with lupus living in Spain and belonging to patient associations in Spain (FELUPUS). •Nationally and to our knowledge, this is the survey with the largest number of participants (N = 1263) conducted in patients with lupus. •Most of the patients claimed they stay up late, exercising and work/study were the most limited actions due to the disease. •73% of patients considered that there is little knowledge of the disease by society and at the time of diagnosis, the patient's level of knowledge about lupus was low in 92% of them.
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Affiliation(s)
| | | | | | - Ricard Cervera
- Department of Autoimmune Diseases, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Norberto López
- Dermatology Service, Hospital Virgen de La Victoria, Málaga, Spain
| | - Lucio Pallares
- Internal Medicine Service, Hospital Universitario Son Espases, Palma, Spain
| | | | - Silvia Pérez Ortega
- FELUPUS (Spanish Lupus Federation), FELUPUS, Madrid, On Behalf of FELUPUS Spain
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Pana TA, Jesenakova S, Carter B, Hollick R, Mohamed MO, Mamas MA, Myint PK. Sex-Specific Outcomes of Acute Stroke in Patients with Systemic Lupus Erythematosus: A National Inpatient Sample Study. J Clin Med 2023; 12:jcm12020462. [PMID: 36675393 PMCID: PMC9865871 DOI: 10.3390/jcm12020462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
Background: Systemic lupus erythematosus (SLE) is an autoimmune disorder associated with increased stroke risk. Its association with stroke outcomes remains poorly understood. In this study, we aimed to compare the sex-specific SLE-associated acute stroke outcomes. Methods: Stroke hospitalisations between 2015 and 2018 from the National Inpatient Sample were analysed. The associations between SLE and outcomes (inpatient mortality, length-of-stay > 4 days and routine discharge) were examined using multivariable logistic regressions, stratifying by sex and adjusting for age, race, stroke type, revascularisation, hospital characteristics and comorbidities. Results: A total of 316,531 records representing 1,581,430 hospitalisations were included. Median (interquartile range) age was 71 (60−82) years. There were 940 (0.06%) males and 6110 (0.39%) females with SLE. There were no associations between SLE and mortality amongst either females (odds ratio (95% confidence interval) = 1.11 (0.84−1.48)) or males (0.81 (0.34−1.94)). Nevertheless, SLE was associated with prolonged hospitalisation (1.17 (1.03−1.32)) and lower odds of routine discharge (0.82 (0.72−0.94)) amongst females. There were no associations between SLE and other adverse outcomes amongst males. Conclusions: The association between SLE and acute stroke outcomes was influenced by sex. While SLE was not associated with mortality in either sex, females with SLE had higher odds of prolonged hospitalisation and lower odds of routine home discharge compared to patients without SLE, while males did not exhibit this increased risk.
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Affiliation(s)
- Tiberiu A. Pana
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Correspondence: (T.A.P.); (P.K.M.); Tel.: +44-(0)-1224-437841 (P.K.M.); Fax: +44-(0)-1224-437911 (P.K.M.)
| | - Sona Jesenakova
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Rosemary Hollick
- EULAR Centre of Excellence in Rheumatology, Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - Mohamed O. Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK
| | - Phyo K. Myint
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- EULAR Centre of Excellence in Rheumatology, Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen AB24 3FX, UK
- Correspondence: (T.A.P.); (P.K.M.); Tel.: +44-(0)-1224-437841 (P.K.M.); Fax: +44-(0)-1224-437911 (P.K.M.)
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8
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Floris A, Chessa E, Sebastiani GD, Prevete I, Iannone F, Coladonato L, Govoni M, Bortoluzzi A, Mosca M, Tani C, Doria A, Iaccarino L, Franceschini F, Fredi M, Conti F, Spinelli FR, Bellisai F, D'Alessandro R, Zanetti A, Carrara G, Scirè CA, Cauli A, Piga M. Glucocorticoid tapering and associated outcome in patients with newly diagnosed systemic lupus erythematosus: the real-world GULP prospective observational study. RMD Open 2022; 8:rmdopen-2022-002701. [PMID: 36581383 PMCID: PMC9806067 DOI: 10.1136/rmdopen-2022-002701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/12/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE A subanalysis of the multicentre Early Lupus inception cohort was performed to investigate the real-world Glucocorticoids (GCs) Use in newly diagnosed systemic lupus erythematosus (SLE) Patients (GULP). METHODS Patients starting prednisone (PDN) ≥5 mg/day and concomitant hydroxychloroquine or immunosuppressant within 12 months of SLE classification were enrolled. Core set variables were recorded at baseline and every 6 months, including changes in PDN dose, European Consensus Lupus Activity Measurement (ECLAM) and Systemic Lupus International Collaborating Clinics damage index. Regression models analysed predictors of tapering PDN<5 mg/day at any time and outcomes associated with different patterns of GCs tapering. RESULTS The GULP study included 127 patients with SLE; 73 (57.5%) tapered and maintained PDN <5 mg/day, and 17 (13.4%) discontinued PDN within a 2-year follow-up. Renal involvement (HR: 0.41; p=0.009) and lower C3 serum levels (HR: 1.04; p=0.025) predicted a lack of PDN tapering below 5 mg/day. High ECLAM scores were associated with a greater probability of increasing PDN dose (OR: 1.6; p=0.004), independently of daily intake. Disease relapse rate did not statistically differ (p=0.706) between patients tapering PDN <5 mg/day (42/99, 42.4%) and those tapering PDN without dropping below 5 mg/day (13/28, 46.4%). Every month on PDN <5 mg/day associated with lower damage accrual (IRR: 0.96; p=0.007), whereas never tapering PDN <5 mg/day associated with a higher risk of developing GC-related damage (OR 5.9; p=0.014). CONCLUSION Tapering PDN <5 mg/day was achieved and maintained in half of newly diagnosed patients with SLE and may represent a good balance between the need to prevent damage accrual and the risk of disease relapse.
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Affiliation(s)
- Alberto Floris
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy,UOC Reumatologia, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Elisabetta Chessa
- UOC Reumatologia, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | | | - Immacolata Prevete
- UOC di Reumatologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Florenzo Iannone
- Dipartimento dell’Emergenza e dei Trapianto di Organi - Sezione di Reumatologia, Università degli Studi di Bari Aldo Moro Scuola di Medicina, Bari, Italy
| | - Laura Coladonato
- Dipartimento dell’Emergenza e dei Trapianto di Organi - Sezione di Reumatologia, Università degli Studi di Bari Aldo Moro Scuola di Medicina, Bari, Italy
| | - Marcello Govoni
- UOC e Sezione di Reumatologia - Azienda Ospedaliero-Universitaria S. Anna, Ferrara, Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - Alessandra Bortoluzzi
- UOC e Sezione di Reumatologia - Azienda Ospedaliero-Universitaria S. Anna, Ferrara, Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - Marta Mosca
- Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy,U.O. Reumatologia, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Chiara Tani
- U.O. Reumatologia, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine - DIMED, Università degli Studi di Padova, Padova, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine - DIMED, Università degli Studi di Padova, Padova, Italy
| | - Franco Franceschini
- Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, Brescia, Italy,UOC di Reumatologia e Immunologia Clinica, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Micaela Fredi
- Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, Brescia, Italy,UOC di Reumatologia e Immunologia Clinica, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabrizio Conti
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Università degli Studi di Roma La Sapienza, Rome, Italy
| | - Francesca Romana Spinelli
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Università degli Studi di Roma La Sapienza, Rome, Italy
| | | | | | - Anna Zanetti
- Epidemiology Unit, Italian Society of Rheumatology, Milano, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society of Rheumatology, Milano, Italy
| | | | - Alberto Cauli
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy,UOC Reumatologia, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Matteo Piga
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy,UOC Reumatologia, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
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9
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Jourde-Chiche N, Costedoat-Chalumeau N, Baumstarck K, Loundou A, Bouillet L, Burtey S, Caudwell V, Chiche L, Couzi L, Daniel L, Deligny C, Dussol B, Faguer S, Gobert P, Gondran G, Huart A, Hummel A, Kalbacher E, Karras A, Lambert M, Le Guern V, Lebourg L, Loubière S, Maillard-Lefebvre H, Maurier F, Pha M, Queyrel V, Remy P, Sarrot-Reynauld F, Verhelst D, Hachulla E, Amoura Z, Daugas E. Weaning of maintenance immunosuppressive therapy in lupus nephritis (WIN-Lupus): results of a multicentre randomised controlled trial. Ann Rheum Dis 2022; 81:1420-1427. [PMID: 35725295 PMCID: PMC9484365 DOI: 10.1136/annrheumdis-2022-222435] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 11/05/2022]
Abstract
Objectives Lupus nephritis (LN) is a frequent complication of systemic lupus erythematosus (SLE). Severe (proliferative) forms of LN are treated with induction immunosuppressive therapy (IST), followed by maintenance IST, to target remission and avoid relapses. The optimal duration of maintenance IST is unknown. The WIN-Lupus trial tested whether IST discontinuation after 2‒3 years was non-inferior to IST continuation for two more years in proliferative LN. Methods WIN-Lupus was an investigator-initiated multicentre randomised controlled trial. Patients receiving maintenance IST with azathioprine or mycophenolate mofetil for 2–3 years, and hydroxychloroquine, were randomised (1:1) into two groups: (1) IST continuation and (2) IST discontinuation. The primary endpoint was the relapse rate of proliferative LN at 24 months. Main secondary endpoints were the rate of severe SLE flares, survival without renal relapse or severe flare, adverse events. Results Between 2011 and 2016, 96 patients (out of 200 planned) were randomised in WIN-Lupus: IST continuation group (n=48), IST discontinuation group (n=48). Relapse of proliferative LN occurred in 5/40 (12.5%) patients with IST continuation and in 12/44 (27.3%) patients with IST discontinuation (difference 14.8% (95% CI −1.9 to 31.5)). Non-inferiority was not demonstrated for relapse rate; time to relapse did not differ between the groups. Severe SLE flares (renal or extrarenal) were less frequent in patients with IST continuation (5/40 vs 14/44 patients; p=0.035). Adverse events did not differ between the groups. Conclusions Non-inferiority of maintenance IST discontinuation after 2‒3 years was not demonstrated for renal relapse. IST discontinuation was associated with a higher risk of severe SLE flares. Trial registration number NCT01284725.
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Affiliation(s)
- Noemie Jourde-Chiche
- Nephrology, AP-HM, Marseille, France .,C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France
| | - Nathalie Costedoat-Chalumeau
- entre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, Universite de Paris, Paris, France.,Centre de référence maladies rares, Hôpital Cochin, AP-HP, Paris, France
| | - Karine Baumstarck
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Anderson Loundou
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Laurence Bouillet
- Internal Medicine, Centre Hospitalier Universitaire Grenoble, Michallon Hospital, Grenoble, France
| | - Stéphane Burtey
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Nephrology, AP-HM, Marseille, France
| | | | | | - Lionel Couzi
- Nephrology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Laurent Daniel
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Laboratoire d'Anatomie Pathologique, AP-HM, Marseille, France
| | | | - Bertrand Dussol
- Nephrology, AP-HM, Marseille, France.,Centre d'Investigation Clinique, AP-HM, Marseille, France
| | - Stanislas Faguer
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | | | | | - Antoine Huart
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | - Aurélie Hummel
- Nephrology, Necker-Enfants Malades Hospitals, Paris, France
| | | | - Adexandre Karras
- Nephrology, Hopital Europeen Georges Pompidou, Paris, France.,Universite Paris Descartes, Paris, France
| | | | | | | | - Sandrine Loubière
- Support Unit for Clinical Research and Health Economics, AP-HM, Marseille, France
| | | | | | - Micheline Pha
- Médecine Interne 2, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | | | | | | | | | - Eric Hachulla
- Internal Medicine, Lille University School of Medicine, Lille, France
| | - Zahir Amoura
- Centre de reference maladies auto-immunes et systemiques, Internal Medicine, AP-HP, Paris, France
| | - Eric Daugas
- Nephrology, AP-HP, Paris, France.,INSERM U1149, Universite de Paris, Paris, France
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10
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Papachristos DA, Gladman DD, Su J, Urowitz MB. Outcomes following antimalarial withdrawal in patients with quiescent systemic lupus erythematosus. Semin Arthritis Rheum 2022; 55:152046. [PMID: 35716465 DOI: 10.1016/j.semarthrit.2022.152046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Antimalarial medications (AMs) are central to the management of SLE. We investigated the rate of flare in lupus patients who withdrew AM after achieving clinical remission for at least one year, compared to those who continued therapy and compared flare rates in cases who tapered AM versus abruptly withdrew. METHODS Cases achieved clinical remission for at least one year then ceased their AM. Index date was defined as the date of complete AM cessation. Controls achieved clinical remission for at least one year and continued AM. Controls were matched according to the duration of AM before remission and the duration of therapy from remission date to case index date. All patients had ≥ 2 years of follow up. RESULTS Of 1573 patients on AM, 165 achieved a one-year remission and then ceased their AM. 96 had adequate follow-up, 88 were successfully matched to one control and 85 to 2 controls for a total of 173 controls. Flare occurred in 61.4% of cases and 45.1% of controls (p = 0.002). 52.3% patients who withdrew AM later restarted it due to disease flare. 88% recaptured control or improved, while 12% did not. Patients who tapered had significantly fewer flares (45.9% vs. 72.6%; p = 0.01). CONCLUSION AMs aid in preventing disease flare even in patients who have achieved prolonged clinical remission. Tapering AM results in lower flare rates. Hence, except in the setting of toxicity, cessation of antimalarial therapy in patients with prolonged disease quiescence is feasible using a slow taper.
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Affiliation(s)
- Danaë A Papachristos
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases University Health Network, Toronto Western Hospital, 399 Bathurst St. 1E-410B, Toronto, Ontario M5T 2S8, Canada
| | - Dafna D Gladman
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases University Health Network, Toronto Western Hospital, 399 Bathurst St. 1E-410B, Toronto, Ontario M5T 2S8, Canada; Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jiandong Su
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases University Health Network, Toronto Western Hospital, 399 Bathurst St. 1E-410B, Toronto, Ontario M5T 2S8, Canada
| | - Murray B Urowitz
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases University Health Network, Toronto Western Hospital, 399 Bathurst St. 1E-410B, Toronto, Ontario M5T 2S8, Canada; Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.
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11
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Almeida-Brasil CC, Hanly JG, Urowitz M, Clarke AE, Ruiz-Irastorza G, Gordon C, Ramsey-Goldman R, Petri M, Ginzler EM, Wallace DJ, Bae SC, Romero-Diaz J, Dooley MA, Peschken C, Isenberg D, Rahman A, Manzi S, Jacobsen S, Lim S, van Vollenhoven RF, Nived O, Jönsen A, Kamen DL, Aranow C, Sanchez-Guerrero J, Gladman DD, Fortin PR, Alarcón GS, Merrill JT, Kalunian K, Ramos-Casals M, Steinsson K, Zoma A, Askanase A, Khamashta MA, Bruce IN, Inanc M, Abrahamowicz M, Bernatsky S. Flares after hydroxychloroquine reduction or discontinuation: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2022; 81:370-378. [PMID: 34911705 PMCID: PMC8862090 DOI: 10.1136/annrheumdis-2021-221295] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/10/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance. METHODS We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). We evaluated person-time contributed while on the initial HCQ dose ('maintenance'), comparing this with person-time contributed after a first dose reduction, and after a first HCQ discontinuation. We estimated time to first flare, defined as either subsequent need for therapy augmentation, increase of ≥4 points in the SLE Disease Activity Index-2000, or hospitalisation for SLE. We estimated adjusted HRs (aHRs) with 95% CIs associated with reducing/discontinuing HCQ (vs maintenance). We also conducted separate multivariable hazard regressions in each HCQ subcohort to identify factors associated with flare. RESULTS We studied 1460 (90% female) patients initiating HCQ. aHRs for first SLE flare were 1.20 (95% CI 1.04 to 1.38) and 1.56 (95% CI 1.31 to 1.86) for the HCQ reduction and discontinuation groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts. CONCLUSIONS SLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.
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Affiliation(s)
- Celline C Almeida-Brasil
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann Elaine Clarke
- Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Caroline Gordon
- Rheumatology Research Group, University of Birmingham, Birmingham, UK
| | | | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ellen M Ginzler
- Medicine/Rheumatology, SUNY Downstate Medical Center, New York City, New York, USA
| | - D J Wallace
- Cedars-Sinai/David Geffen School of Medicine at UCLA, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University, Seongdong-gu, Seoul, The Republic of Korea
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Mary Anne Dooley
- Medicine, Unversity of North Carolina, Chapel Hill, North Carolina, USA
| | - Christine Peschken
- Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Isenberg
- Division of Medicine, University College London, London, UK
| | | | - Susan Manzi
- Allegheny Singer Research Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Sam Lim
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Ola Nived
- Rheumatology, Lund University, Lund, Sweden
| | - Andreas Jönsen
- Faculty of Medicine, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
| | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Cynthia Aranow
- Northwell Health Feinstein Institutes for Medical Research Institute of Health Innovations and Outcomes Research, Manhasset, New York, USA
| | - Jorge Sanchez-Guerrero
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Paul R Fortin
- Medicine-Rheumatology, Université Laval, Quebec, Quebec, Canada
| | - Graciela S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Center for Health Promotion, Birmingham, Alabama, USA
| | - Joan T Merrill
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Kristján Steinsson
- Rheumatology, Department of Obstetrics and Gynecology, Landspitali University Hospital, Reyjavik, Iceland
| | - Asad Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, South Lanarkshire, UK
| | - Anca Askanase
- Rheumatology, Columbia University Medical Center, New York, New York, USA
| | | | - Ian N Bruce
- Arc Epidemiology Unit, The University of Manchester, Manchester, UK
| | - Murat Inanc
- Department of Internal Medicine, Division of Rheumatology, Istanbul University, Fatih, Istanbul, Turkey
| | - Michal Abrahamowicz
- Department of Epidemiology Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sasha Bernatsky
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
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12
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Moroni G, Frontini G, Ponticelli C. When and How Is It Possible to Stop Therapy in Patients with Lupus Nephritis: A Narrative Review. Clin J Am Soc Nephrol 2021; 16:1909-1917. [PMID: 34162696 PMCID: PMC8729481 DOI: 10.2215/cjn.04830421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Glucocorticoids and other immunosuppressants still represent the cornerstone drugs for the management of SLE and lupus nephritis. The refined use of these drugs over the years has allowed us to obtain stable disease remission and improvement of long-term kidney and patient survival. Nevertheless, a prolonged use of immunosuppressive agents may be accompanied by severe and even life-threatening side effects. Theoretically, a transient or even definitive withdrawal of immunosuppression could be useful to prevent iatrogenic morbidities. For many years, however, the risk of SLE reactivation has held clinicians back from trying to interrupt therapy. In this review, we report the results of the attempts to interrupt glucocorticoids and other immunosuppressive agents in lupus nephritis and in SLE. The available data suggest that therapy withdrawal is feasible at least in patients enjoying a complete clinical remission after a prolonged therapy. A slow and gradual reduction of treatment under medical surveillance is needed to prevent flares of activity. After therapy withdrawal, around one-quarter of patients may have kidney or systemic flares. However, most flares may respond to therapy if rapidly diagnosed. The other patients can enter stable remission for even 20 years or more. The use of antimalarials can help in maintaining the remission after the withdrawal of the immunosuppressive therapy. A repeated kidney biopsy could be of help in deciding to stop therapy, but given the few available data, it cannot be considered essential.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Giulia Frontini
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
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13
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Tselios K, Gladman DD, Su J, Urowitz MB. Gradual Glucocorticosteroid Withdrawal Is Safe in Clinically Quiescent Systemic Lupus Erythematosus. ACR Open Rheumatol 2021; 3:550-557. [PMID: 34245233 PMCID: PMC8363847 DOI: 10.1002/acr2.11267] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
Objectives Patients with systemic lupus erythematosus (SLE) are usually treated with glucocorticosteroids even during periods of clinically quiescent disease. A recent study showed that abrupt glucocorticoid withdrawal was associated with an increased likelihood of flare in the next 12 months. The aim of the present study was to assess clinical flare rates and damage accrual in patients who tapered glucocorticosteroids gradually. Methods Patients from the Toronto Lupus Clinic with 2 consecutive years of clinically quiescent disease were retrieved from the database. Individuals who maintained a low prednisone dose (5 mg/day) comprised the maintenance group, whereas patients who gradually tapered prednisone within these two years comprised the withdrawal group. All individuals were followed for 2 years after prednisone discontinuation or the corresponding date for the maintenance group. Propensity score matching was implemented to adjust for certain baseline differences. Outcomes included clinical flares and damage accrual. Results Of 270 eligible patients, 204 were matched (102 in each group). Flare rate (any increase in clinical SLE Disease Activity Index 2000) was lower in the withdrawal group both at 12 (17.6% versus 29.4%; P = 0.023) and 24 months (33.3% versus 50%; P = 0.01). Moderate to severe flares (requiring systemic treatment escalation) were not different at 12 months (10.8% versus 13.7%; P = 0.467) but were less frequent at 24 months (14.7% versus 27.5%; P = 0.024). Damage accrual was less frequent in the withdrawal group (6.9% versus 17.6%; P = 0.022). No predictors for clinical flares were identified. Conclusion Gradual glucocorticoid withdrawal is safe in clinically quiescent SLE and is associated with fewer clinical flares and less damage accrual at 24 months.
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Affiliation(s)
- Konstantinos Tselios
- University of Toronto Lupus ClinicCentre of Prognosis Studies in the Rheumatic DiseasesUniversity Health NetworkTorontoOntarioCanada
| | - Dafna D. Gladman
- University of Toronto Lupus ClinicCentre of Prognosis Studies in the Rheumatic DiseasesUniversity Health NetworkTorontoOntarioCanada
| | - Jiandong Su
- University of Toronto Lupus ClinicCentre of Prognosis Studies in the Rheumatic DiseasesUniversity Health NetworkTorontoOntarioCanada
| | - Murray B. Urowitz
- University of Toronto Lupus ClinicCentre of Prognosis Studies in the Rheumatic DiseasesUniversity Health NetworkTorontoOntarioCanada
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14
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Isenberg D, Furie R, Jones NS, Guibord P, Galanter J, Lee C, McGregor A, Toth B, Rae J, Hwang O, Desai R, Lokku A, Ramamoorthi N, Hackney JA, Miranda P, de Souza VA, Jaller-Raad JJ, Maura Fernandes A, Garcia Salinas R, Chinn LW, Townsend MJ, Morimoto AM, Tuckwell K. Efficacy, Safety, and Pharmacodynamic Effects of the Bruton's Tyrosine Kinase Inhibitor Fenebrutinib (GDC-0853) in Systemic Lupus Erythematosus: Results of a Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Arthritis Rheumatol 2021; 73:1835-1846. [PMID: 34042314 DOI: 10.1002/art.41811] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/11/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Fenebrutinib (GDC-0853) is a noncovalent, oral, and highly selective inhibitor of Bruton's tyrosine kinase (BTK). The efficacy, safety, and pharmacodynamics of fenebrutinib in systemic lupus erythematosus (SLE) were assessed in this phase II, multicenter, randomized, placebo-controlled study. METHODS Patients who had moderately to severely active SLE while receiving background standard therapy were randomized to receive placebo, fenebrutinib 150 mg once daily, or fenebrutinib 200 mg twice daily. Glucocorticoid taper was recommended from weeks 0 to 12 and from weeks 24 to 36. The primary end point was the SLE Responder Index 4 (SRI-4) response at week 48. RESULTS Patients (n = 260) were enrolled from 44 sites in 12 countries, with the majority from Latin America, the US, and Western Europe. The SRI-4 response rates at week 48 were 51% for fenebrutinib 150 mg once daily (P = 0.37 versus placebo), 52% for fenebrutinib 200 mg twice daily (P = 0.34 versus placebo), and 44% for placebo. British Isles Lupus Assessment Group-based Combined Lupus Assessment response rates at week 48 were 53% for fenebrutinib 150 mg once daily (P = 0.086 versus placebo), 42% for fenebrutinib 200 mg twice daily (P = 0.879 versus placebo), and 41% for placebo. Safety results were similar across all arms, although serious adverse events were more frequent with fenebrutinib 200 mg twice daily. By week 48, patients treated with fenebrutinib had reduced levels of a BTK-dependent plasmablast RNA signature, anti-double-stranded DNA autoantibodies, total IgG, and IgM, as well as increased complement C4 levels, all relative to placebo. CONCLUSION While fenebrutinib had an acceptable safety profile, the primary end point, SRI-4 response, was not met despite evidence of strong pathway inhibition.
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Affiliation(s)
| | | | | | | | | | - Chin Lee
- Genentech, Inc., South San Francisco, California
| | | | - Balazs Toth
- Genentech, Inc., South San Francisco, California
| | - Julie Rae
- Genentech, Inc., South San Francisco, California
| | - Olivia Hwang
- Genentech, Inc., South San Francisco, California
| | - Rupal Desai
- Genentech, Inc., South San Francisco, California
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15
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Margherita Z, Enrico F, Marta LM, Roberto D, Micaela F, Mariele G, Maddalena L, Francesca S, Luca I, Andrea D. Immunosuppressive therapy withdrawal after remission achievement in patients with lupus nephritis. Rheumatology (Oxford) 2021; 61:688-695. [PMID: 33909900 DOI: 10.1093/rheumatology/keab373] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/16/2021] [Indexed: 12/14/2022] Open
Abstract
AIM Whether immunosuppressive therapy (IS) may be safely withdrawn in lupus nephritis (LN) is still unclear. We assessed rate and predictors of flare after IS withdrawal in patients with LN in remission. METHODS Patients with biopsy-proven LN treated with IS between 1980 and 2020 were considered. Remission was defined as normal serum creatinine, proteinuria <0.5 g/24h, inactive urine sediment, and no extra-renal SLE activity on stable immunosuppressive and/or antimalarial therapy and/or prednisone ≤5mg/day. IS discontinuation was defined as the complete withdrawal of immunosuppressants, flares according to SLEDAI Flare Index. Predictors of flare were analyzed by multivariate logistic regression analysis. RESULTS Among 513 SLE patients included in our database, 270 had LN. Of them, 238 underwent renal biopsy and were treated with ISs. Eighty-three patients (34.8%) discontinued IS, 46 ± 30 months after remission achievement. During a mean±SD follow-up of 116.5 ± 78 months, 19 patients (22.8%) developed a flare (8/19 renal) and were re-treated; 14/19 (73.7%) re-achieved remission after restarting therapy. Patients treated with IS therapy for at least three years after remission achievement had the lowest risk of relapse (OR 0.284, 95% CI 0.093-0.867, p= 0.023). At multivariate analysis, antimalarial maintenance therapy (OR 0.194, 95%CI 0.038-0.978, p= 0.047), age at IS discontinuation (OR 0.93, 95%CI 0.868-0.997, p= 0.040), remission duration >3 years before IS discontinuation (OR 0.231, 95%CI 0.058-0.920, p= 0.038) were protective against disease flares. CONCLUSIONS Withdrawal of IS is feasible in LN patients in remission for at least 3 years and on antimalarial therapy. Patients who experience flares can re-achieve remission with an appropriate treatment.
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Affiliation(s)
- Zen Margherita
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Fuzzi Enrico
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Loredo Martinez Marta
- Division of Rheumatology, Lozano Blesa University Clinical Hospital, Zaragoza, Aragón, Spain
| | - Depascale Roberto
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Fredi Micaela
- Rheumatology and Clinical Immunology Unit, Clinical and Experimental Science Department, ASST Spedali Civili and University of Brescia, Italy
| | - Gatto Mariele
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Larosa Maddalena
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Saccon Francesca
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Iaccarino Luca
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Doria Andrea
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
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16
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Fischer-Betz R, Schneider M. [Deescalation and glucocorticoid-free treatment in SLE]. Z Rheumatol 2021; 80:332-338. [PMID: 33721043 DOI: 10.1007/s00393-021-00981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
Treatment of systemic lupus erythematosus (SLE) without permanent glucocorticoid therapy is inconceivable for most patients and their physicians. Although we have significantly improved the prognosis of SLE, management remains constrained by a lack of effective, targeted therapies and the lack of evidence-based approaches to the use of existing compounds. For example, for glucocorticoids (GC), which are used continuously in a majority of patients, there are no evidence-based recommendations for initiation, tapering, and cessation in the treatment of SLE. Even today, GC are without alternatives in acute situations, especially organ- or life-threatening ones. However, due to the known long-term adverse effects, the role of GC is viewed increasingly critically. Long-term data from cohorts show that the use of GC actually contributes to morbidity and mortality in SLE. Strategies to reduce the use of GC in SLE are therefore urgently needed and are proposed in this paper.
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Affiliation(s)
- Rebecca Fischer-Betz
- Poliklinik für Rheumatologie und Hiller Forschungszentrum, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Matthias Schneider
- Poliklinik für Rheumatologie und Hiller Forschungszentrum, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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17
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Fasano S, Coscia MA, Pierro L, Ciccia F. Which patients with systemic lupus erythematosus in remission can withdraw low dose steroids? Results from a single inception cohort study. Lupus 2021; 30:991-997. [PMID: 33709836 DOI: 10.1177/09612033211002269] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND A progressive tapering until withdrawal of glucocorticoids (GC) is considered one of the main goals of Systemic Lupus Erythematosus (SLE) management. However, which patient may be a candidate for safe GC withdrawal has not been determined yet. This study aimed to evaluate the rate of low-dose GC withdrawal in SLE patients in remission and to identify predictors of flares. METHODS Eligible patients were SLE patients in prolonged clinical remission defined by a cSLEDAI = 0 for at least 2 years and on a stable SLE treatment (including daily 5 mg prednisone). Flares were defined by SELENA-SLEDAI Flare Index. Predictors of flares after GC withdrawal were analyzed by Cox regression. RESULTS We selected 56 patients in whom a GC withdrawal was attempted. 98 patients were in the prednisone maintenance group. The proportion of patients experiencing a flare was not significantly lower in the maintenance group than in the withdrawal group (p = 0.81). However, among the withdrawal group, the rate of flares was significantly higher in serologically active clinically quiescent (SACQ) patients (p < 0,0001). At Cox regression analysis, duration of hydroxychloroquine (HCQ) therapy and ≥5 year remission at withdrawal were protective factors, while a SACQ disease and history of lupus nephritis increased the risk of disease flare. CONCLUSION GC withdrawal is an achievable target in SLE and may be attempted in patients in complete remission.However, it might underline a caution in patients with SACQ disease who may be at greater risk forflare when GCare discontinued. HCQ therapy and durable remission can significantly reduce the risk.
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Affiliation(s)
- Serena Fasano
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | | | - Luciana Pierro
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Francesco Ciccia
- Rheumatology Unit, University of Campania "Luigi Vanvitelli", Caserta, Italy
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18
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Andrade SDO, Julio PR, Nunes de Paula Ferreira D, Appenzeller S. Predicting lupus flares: epidemiological and disease related risk factors. Expert Rev Clin Immunol 2021; 17:143-153. [PMID: 33393397 DOI: 10.1080/1744666x.2020.1865156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder, characterized by a relapsing and remitting pattern of disease activity in majority of the patients. Areas covered: This narrative review provides an overview of flare definition, major flare mimics, and the burden of flares in SLE. The authors highlight epidemiology and disease-related risk factor for flares and discuss strategies to reduce flares in SLE. Articles were selected from Pubmed searches conducted between June 2020 and September 2020. Expert opinion: Prolonged clinical remission is observed in approximately 20% of SLE patients flare over the course of the disease. Studies have shown that low disease activity is a good target in SLE, with similar risk of flares, mortality, and quality of life when compared to patients in remission. Clinical and immunological features have shown inconsistent results to identify patients at risk of flares in different cohorts. Cytokine, in serum and urine, has shown promising results to predict flares. However to be useful in clinical practice, they have to be simple, easy, and cost-effective. Future efforts in this direction will allow a more personalized treatment plan for SLE patients, reducing the burden associated with flares.
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Affiliation(s)
- Samuel de Oliveira Andrade
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science-University of Campinas, Brazil.,Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil
| | - Paulo Rogerio Julio
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil
| | - Diego Nunes de Paula Ferreira
- Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
| | - Simone Appenzeller
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
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19
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Mathian A, Pha M, Amoura Z. [Therapeutic de-escalation in systemic lupus erythematosus in remission]. Rev Med Interne 2020; 41:795-799. [PMID: 33234319 DOI: 10.1016/j.revmed.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Affiliation(s)
- A Mathian
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - M Pha
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France
| | - Z Amoura
- Sorbonne université, Assistance Publique-Hôpitaux de Paris, groupement hospitalier Pitié-Salpêtrière, Centre de Référence pour le Lupus, le Syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine Interne 2, institut E3M, Inserm UMRS, centre d'immunologie et des maladies infectieuses (CIMI-Paris), Paris, France.
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20
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Mathian A, Pha M, Yssel H, Amoura Z. Reducing lupus flares: should we be more careful about stopping glucocorticoids? Expert Rev Clin Immunol 2020; 16:539-542. [PMID: 32666853 DOI: 10.1080/1744666x.2020.1778466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Alexis Mathian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris) , Paris, France
| | - Micheline Pha
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris) , Paris, France
| | - Hans Yssel
- Inserm UMR-S, Centre d'Immunologie Et Des Maladies Infectieuses (Cimi-paris) , Paris, France
| | - Zahir Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris) , Paris, France
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21
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Mathian A, Pha M, Haroche J, Cohen-Aubart F, Hié M, Pineton de Chambrun M, Boutin THD, Miyara M, Gorochov G, Yssel H, Cherin P, Devilliers H, Amoura Z. Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial. Ann Rheum Dis 2019; 79:339-346. [PMID: 31852672 DOI: 10.1136/annrheumdis-2019-216303] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To compare the efficacy to prevent flares of maintenance versus withdrawal of 5 mg/day prednisone in systemic lupus erythematosus (SLE) patients with clinically quiescent disease. METHODS A monocentric, 12-month, superiority, open-label, randomised (1:1) controlled trial was conducted with 61 patients continuing 5 mg/day prednisone and 63 stopping it. Eligibility criteria were SLE patients who, during the year preceding the inclusion, had a clinically inactive disease and a stable SLE treatment including 5 mg/day prednisone. The primary endpoint was the proportion of patient experiencing a flare defined with the SELENA-SLEDAI flare index (SFI) at 52 weeks. Secondary endpoints included time to flare, flare severity according to SFI and British Isles Lupus Assessment Group (BILAG) index and increase in the Systemic Lupus International Collaborating Clinics (SLICC) damage index (SDI). RESULTS Proportion of patients experiencing a flare was significantly lower in the maintenance group as compared with the withdrawal group (4 patients vs 17; RR 0.2 (95% CI 0.1 to 0.7), p=0.003). Maintenance of 5 mg prednisone was superior with respect to time to first flare (HR 0.2; 95% CI 0.1 to 0.6, p=0.002), occurrence of mild/moderate flares using the SFI (3 patients vs 12; RR 0.2 (95% CI 0.1 to 0.8), p=0.012) and occurrence of moderate/severe flares using the BILAG index (1 patient vs 8; RR 0.1 (95% CI 0.1 to 0.9), p=0.013). SDI increase and adverse events were similar in the two treatment groups. Subgroup analyses of the primary endpoint by predefined baseline characteristics did not show evidence of a different clinical response. CONCLUSION Maintenance of long term 5 mg prednisone in SLE patients with inactive disease prevents relapse. TRIAL REGISTRATION NUMBER NCT02558517; Results.
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Affiliation(s)
- Alexis Mathian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Micheline Pha
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Julien Haroche
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Fleur Cohen-Aubart
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Miguel Hié
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Thi Huong Du Boutin
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Makoto Miyara
- Sorbonne Université, Inserm UMR-S, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, Département d'Immunologie, Paris, France
| | - Guy Gorochov
- Sorbonne Université, Inserm UMR-S, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, Département d'Immunologie, Paris, France
| | - Hans Yssel
- Sorbonne Université, Inserm UMR-S, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, Département d'Immunologie, Paris, France
| | - Patrick Cherin
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Hervé Devilliers
- Centre Hospitalier Universitaire de Dijon, Hôpital François-Mitterrand, service de médecine interne et maladies systémiques (médecine interne 2) et Centre d'Investigation Clinique, Inserm CIC-EC 1432, Dijon, France
| | - Zahir Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
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22
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Zen M, Saccon F, Gatto M, Montesso G, Larosa M, Benvenuti F, Iaccarino L, Doria A. Prevalence and predictors of flare after immunosuppressant discontinuation in patients with systemic lupus erythematosus in remission. Rheumatology (Oxford) 2019; 59:1591-1598. [DOI: 10.1093/rheumatology/kez422] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/14/2019] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objectives
Patients with SLE are often exposed to prolonged immunosuppression since few data on flare recurrence in remitted patients who discontinued immunosuppressants are available. We aimed to assess the rate and predictors of flare after immunosuppressant withdrawal in SLE patients in remission.
Methods
SLE patients diagnosed between 1990 and 2018 (according to the ACR criteria), ever treated with immunosuppressants and currently in follow-up were considered. Immunosuppressant discontinuation was defined as complete withdrawal of any immunosuppressive drug. Reasons for discontinuation were remission, defined as clinical SLEDAI-2K = 0 on a stable immunosuppressive and/or antimalarial therapy and/or on prednisone ⩽5 mg/day, or poor adherence/intolerance. Flares were defined according to the SLEDAI Flare Index. Predictors of a subsequent flare were analysed by multivariate logistic regression.
Results
There were 319 eligible patients out of 456 (69.9%). Of the 319 patients, 139 (43.5%) discontinued immunosuppressants, 105 (75.5%) due to remission, 34 (24.5%) due to poor adherence/intolerance. The mean (s.d.) follow-up time after immunosuppressant withdrawal was 91 (71) months (range 6–372). Among the patients who discontinued immunosuppressants, 26/105 remitted (24.7%) and 23/34 unremitted patients (67.6%) experienced a flare (P < 0.001) after a median (range) follow-up of 57 (6–264) and 8 months (1–72), respectively (P = 0.009). In patients who discontinued immunosuppressants due to remission, maintenance therapy with antimalarials (OR 0.243, 95% CI 0.070, 0.842) and the duration of remission at immunosuppressant discontinuation (OR 0.870, 0.824–0.996) were independent protective factors against disease flare.
Conclusion
SLE flares are not uncommon after immunosuppressant discontinuation, even in remitted patients; however, antimalarial therapy and durable remission can significantly reduce the risk of flare.
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Affiliation(s)
- Margherita Zen
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Francesca Saccon
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Giulia Montesso
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Francesco Benvenuti
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
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23
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Tani C, Elefante E, Signorini V, Zucchi D, Lorenzoni V, Carli L, Stagnaro C, Ferro F, Mosca M. Glucocorticoid withdrawal in systemic lupus erythematosus: are remission and low disease activity reliable starting points for stopping treatment? A real-life experience. RMD Open 2019; 5:e000916. [PMID: 31275608 PMCID: PMC6579574 DOI: 10.1136/rmdopen-2019-000916] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/02/2019] [Accepted: 05/09/2019] [Indexed: 12/26/2022] Open
Abstract
Objectives To evaluate the proportion of patients who have successfully withdrawn glucocorticoids (GCs) in a longitudinal cohort of patients with systemic lupus erythematosus (SLE) over a period of 6 years; to evaluate patient characteristics during GC withdrawal in relation to existing definitions of remission and Lupus Low Disease Activity State (LLDAS); and to evaluate the occurrence of flares after GC withdrawal. Methods Patients who attempted GC withdrawal were identified for the cohort, and the following information was assessed during withdrawal attempts: date of last disease flare, disease activity and damage and ongoing treatment. Information regarding the occurrence of disease flares after GC withdrawal was also recorded for patients who successfully stopped treatment.Definitions of remission were applied to GC withdrawal in line with European consensus criteria (Definitions of remission in SLE [DORIS]) and LLDAS in line with the Asian Pacific Lupus Consortium definition. Results 148 patients were involved in the study; GC withdrawal was attempted in 91 patients (61.5%) with 77 patients (84.6%) successfully stopping GCs. At the beginning of the GC reduction, the majority of patients were in complete or clinical remission (48.9% and 39.6%, respectively). Disease activity was significantly lower in patients who successfully stopped GCs, and the proportion of patients in complete remission was higher (54.2%) with respect to patients who failed in their attempt. Among patients who stopped GCs, 18 flares were recorded after a median of 1 year. The time period since the last flare was shorter in patients who experienced flares with respect to patients who did not flare (mean 0.93 years vs 6.0, p<0.001). Conclusions GC withdrawal is an achievable goal in SLE and may be attempted after a long-term remission or LLDAS to protect the patient from disease flares.
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Affiliation(s)
- Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Viola Signorini
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dina Zucchi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Linda Carli
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Chiara Stagnaro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Giannakou I, Chatzidionysiou K, Magder LS, Györi N, van Vollenhoven R, Petri MA. Predictors of persistent disease activity and long quiescence in systemic lupus erythematosus: results from the Hopkins Lupus Cohort. Lupus Sci Med 2018; 5:e000287. [PMID: 30538818 PMCID: PMC6257375 DOI: 10.1136/lupus-2018-000287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/09/2018] [Accepted: 09/11/2018] [Indexed: 12/24/2022]
Abstract
Objectives The aim of this study is to identify prognostic factors of persistent disease activity and long quiescence in systemic lupus erythematosus (SLE). Methods Patients enrolled in the Hopkins Lupus Cohort from 1987 to 2012, who attended at least three visits per year during 3 consecutive years following baseline and had available information on disease activity were included. Patterns of SLE disease activity over the 3-year period were defined as: persistent long quiescent (pLQ), persistent relapsing-remitting (pRR), persistent chronic active (pCA) and mixed based on Modified SLE Disease Activity Index (M-SLEDAI). Possible predictors of pCA (vs pLQ, pRR and mixed) and pLQ (vs pCA, pRR and mixed) were identified by univariate and multivariate logistic regression analyses. Results 916 patients were included. In the multivariate analysis, use of hydroxychloroquine (OR: 0.45, 95% CI 0.22 to 0.92, p=0.03), African American ethnicity (OR: 2.36, 95% CI 1.15 to 4.85, p=0.02) and baseline SLEDAI (OR: 1.10, 95% CI 1.03 to 1.17, p=0.005) remained significant predictors of pCA. Higher education (>12 years; OR. 2.07, 95% CI 1.07 to 4.03, p=0.03) and lower baseline SLEDAI (OR: 0.67, 95% CI 0.56 to 0.82, p<0.001) were significant predictors of pLQ, while African American (OR: 0.38, 95% CI 0.17 to 0.83, p=0.02) and female patients (OR: 0.26, 95% CI 0.12 to 0.57, p<0.001) were less likely to achieve pLQ. Conclusion African American ethnicity and high disease activity at baseline predict chronic activity in SLE, regardless of treatment, years of education and income. Higher education, low disease activity at baseline and male sex predict long quiescence. The use of hydroxychloroquine is independently associated with a lower risk of chronically active disease.
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Affiliation(s)
- Ioanna Giannakou
- ClinTRID - Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Department of Medical Sciences, Science for Life Laboratory, Rheumatology, Uppsala University, Uppsala, Sweden
| | - Katerina Chatzidionysiou
- ClinTRID - Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Noemi Györi
- ClinTRID - Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Ronald van Vollenhoven
- ClinTRID - Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Department of Rheumatology, Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, The Netherlands
| | - Michelle A Petri
- Division of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Moroni G, Gatto M, Raffiotta F, Binda V, Frangou E, Lightstone L, Boumpas DT. Can we withdraw immunosuppressants in patients with lupus nephritis in remission? An expert debate. Autoimmun Rev 2018; 17:11-18. [DOI: 10.1016/j.autrev.2017.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/04/2017] [Indexed: 12/30/2022]
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