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Kostopoulou M, Mukhtyar CB, Bertsias G, Boumpas DT, Fanouriakis A. Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations. Ann Rheum Dis 2024:ard-2023-225319. [PMID: 38777375 DOI: 10.1136/ard-2023-225319] [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: 11/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To analyse the new evidence (2018-2022) for the management of systemic lupus erythematosus (SLE) to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations. METHODS Systematic literature reviews were performed in the Medline and the Cochrane Library databases capturing publications from 1 January 2018 through 31 December 2022, according to the EULAR standardised operating procedures. The research questions focused on five different domains, namely the benefit/harm of SLE treatments, the benefits from the attainment of remission/low disease activity, the risk/benefit from treatment tapering/withdrawal, the management of SLE with antiphospholipid syndrome and the safety of immunisations against varicella zoster virus and SARS-CoV2 infection. A Population, Intervention, Comparison and Outcome framework was used to develop search strings for each research topic. RESULTS We identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomised controlled trials (RCTs) documented the efficacy of the type 1 interferon receptor inhibitor, anifrolumab, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN), when compared with standard of care. For the treatment of specific organ manifestations outside LN, a lack of high-quality data was documented. Multiple observational studies confirmed the beneficial effects of attaining clinical remission or low disease activity, reducing the risk for multiple adverse outcomes. Two randomised trials with some concerns regarding risk of bias found higher rates of relapse in patients who discontinued glucocorticoids (GC) or immunosuppressants in SLE and LN, respectively, yet observational cohort studies suggest that treatment withdrawal might be feasible in a subset of patients. CONCLUSION Anifrolumab and belimumab achieve better disease control than standard of care in extrarenal SLE, while combination therapies with belimumab and voclosporin attained higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favourable long-term outcomes. In patients achieving these targets, GC and immunosuppressive therapy may gradually be tapered. Cite Now.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete, School of Medicine, Heraklion, Greece
- Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Oiwa H, Suga T, Hosokawa Y, Araki K. Glucocorticoid-free remission in patients with SLE in the era of biologics: Immune complex disease is likely to benefit from current medications. Lupus 2024; 33:502-510. [PMID: 38470859 DOI: 10.1177/09612033241238055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVES In addition to various immunosuppressive agents, belimumab and anifrolumab became available in Japan. We aimed to investigate glucocorticoid-free clinical remission in a single-centre retrospective cohort in October 2023. METHODS Our cohort included patients with SLE who needed to start or increase glucocorticoids for disease activity and were followed up for more than 1 year. We investigated the rate of achievement of clinical remission off corticosteroids (CR off C), defined as no clinical score on the SLEDAI-2K without glucocorticoids, baseline predictors of CR off C, medications used when CR off C was achieved, and flare rates following CR off C. RESULTS Out of the 60 patients followed for an average of 5.4 (±2.6) years, 17 (28.3%) achieved CR off C in 3.6 (±1.2) years after enrolment. Use of belimumab and anifrolumab accounted for eight (47.1%) of the achievers. Among the baseline data, male sex, recent enrolment, high glucocorticoid dose, and detection of immune complex (IC) significantly predicted CR off C, while lupus nephritis (LN) and a low C3 level tended to predict it. In the multivariate analysis, IC detection was the only predictor of CR off C. Clinical flares were observed in 5.9% of the achievers during a median 1.2 years after achievement of CR off C. CONCLUSION In the era of biologics, CR off C was achieved in 28.3% of the patient cohort requiring the start or increase of glucocorticoids for disease activity, with a relatively low rate of flares, suggesting that glucocorticoid-free clinical remission is an achievable target in SLE. IC disease, represented by male sex or nephritis, is likely to benefit from currently available medications.
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Affiliation(s)
- Hiroshi Oiwa
- Department of Rheumatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Takeshi Suga
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yohei Hosokawa
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kei Araki
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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Nakai T, Honda N, Soga E, Fukui S, Kitada A, Yokogawa N, Okada M. Effect of remission, clinical remission with active serology, and glucocorticoid dosage on the pregnancy outcome of pregnant patients with systemic lupus erythematosus. Arthritis Res Ther 2024; 26:63. [PMID: 38459603 PMCID: PMC10924338 DOI: 10.1186/s13075-024-03298-6] [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: 08/14/2023] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Remission is a key treatment target in systemic lupus erythematosus (SLE) management. Given the direct correlation between lupus flares and elevated risks of adverse pregnancy outcomes (APOs), securing remission before conception becomes crucial. However, the association between clinical remission with active serology, and the risk of APOs is not thoroughly understood. Additionally, determining the optimal glucocorticoid dosage during pregnancy to mitigate APO risks remains under-researched. This study investigated the risk of APOs in relation to remission/serological activity status in patients in clinical remission/glucocorticoid dosage. METHODS Pregnant patients with SLE, who were followed up at two Japanese tertiary referral centers, and had their remission status assessed at conception, were included in this study. We categorized the patients into two groups based on whether they achieved Zen/Doria remission at conception and analyzed the APO ratio. We also examined the influence of serological activity in pregnant patients with clinical remission and analyzed the optimal glucocorticoid dosage to minimize the APO ratio. RESULTS Of the 96 pregnancies included, 59 achieved remission at conception. Pregnant patients who achieved remission showed a significant decrease in the APO ratio compared with those who did not. (overall APO: odds ratio (OR) 0.27, 95% confidence interval (CI) 0.11-0.65, p < 0.01, maternal APO: OR 0.34, 95%CI 0.13-0.85, p = 0.021, neonatal APO: OR 0.39, 95%CI 0.17-0.90, p = 0.028). Conversely, no statistical difference was observed in the APO ratio based on serological activity in pregnant patients with clinical remission. (overall APO: OR 0.62, 95%CI 0.21-1.79, p = 0.37, maternal APO: OR 1.25, 95%CI 0.32-4.85, p = 0.75, neonatal APO: OR 0.83, 95%CI 0.29-2.39, p = 0.73). A glucocorticoid dose of prednisolone equivalent ≥ 7.5 mg/day at conception correlated with increased APO. (overall APO: OR 3.01, 95%CI 1.23-7.39, p = 0.016, neonatal APO: OR 2.98, 95% CI:1.23-7.22, p = 0.016). CONCLUSIONS Even with active serology, achieving clinical remission can be a clinical target for reducing APOs in patients who wish to conceive. In addition, if clinically feasible, reducing the glucocorticoid dosage to < 7.5 mg/day before conception could be another predictive factor.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan.
| | - Nanase Honda
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Eri Soga
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ayako Kitada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
- Department of Rheumatology, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, Japan
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Nakai T, Fukui S, Sawada H, Ikada Y, Tamaki H, Kishimoto M, Okada M. Disease-modifying effect and long-term safety of belimumab in patients with systemic lupus erythematosus: A single-center retrospective study. Lupus 2023; 32:1518-1527. [PMID: 37858981 DOI: 10.1177/09612033231208845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Disease modification in systemic lupus erythematosus (SLE) is important for minimizing disease activity while limiting treatment-associated toxicities. Belimumab can be used as a remission-induction/maintenance systemic lupus erythematosus therapy; however, its disease-modifying effects are unclear. We aimed to determine these effects in patients with systemic lupus erythematosus. METHODS This single-center retrospective cohort study included 92 patients with systemic lupus erythematosus treated with belimumab. We analyzed the changes in flare free rate/lupus low disease activity state (LLDAS) attainment rate/glucocorticoid dosage/Systemic Lupus International Collaborating Clinics and American College of Rheumatology damage index (SDI) score/drug retention rate after treatment initiation. RESULTS Fifty-two weeks after initiating belimumab, the flare rate decreased from 82.6% to 14.1% (p < .01). Until week 52 and 1000 days after initiating belimumab treatment, > 70% and ∼90% of the patients attained lupus low disease activity state, respectively. Belimumab treatment significantly reduced glucocorticoid demand (initiation day, 8.88 (6.00-15.00) mg/d; week 52, 5.00 (2.00-7.00) mg/d; final day of the study period, 3.00 (0.46-6.06) mg/d, initiation day vs. week 52: p < .01, initiation day vs. final day: p < .01); at the end of the study period, 68.5% of patients required ≤5 mg/d prednisolone, and 22.8% discontinued glucocorticoids. Most patients were SDI progression-free (week 52, ∼95%; day 1000, ∼90%), and belimumab showed a high drug retention rate (week 52, 90%; day 1000 > 80%). CONCLUSION Most patients experienced lupus low disease activity state, reduced flare rate and glucocorticoid demand, and a stable SDI trend after belimumab treatment initiation. Given its efficacy and retention rate, belimumab treatment may serve as a fundamental strategy in disease modification.
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Affiliation(s)
- Takehiro Nakai
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
| | - Sho Fukui
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
- Center for Clinical Epidemiology, St Luke's International University, Tokyo, Japan
- Department of Emergency and General Medicine, Kyorin University School of Medicine, Tokyo, Japan
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, MA, USA
| | - Haruki Sawada
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Yukihiko Ikada
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
| | - Hiromichi Tamaki
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St Luke's International Hospital, Tokyo, Japan
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Jourde-Chiche N, Bobot M, Burtey S, Chiche L, Daugas E. Weaning Maintenance Therapy in Lupus Nephritis: For Whom, When, and How? Kidney Int Rep 2023; 8:1481-1488. [PMID: 37547513 PMCID: PMC10403675 DOI: 10.1016/j.ekir.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
Lupus nephritis (LN) is one of the main determinants of the severity of systemic lupus erythematosus (SLE). LN flares can lead to organ damage with chronic kidney disease (CKD) or even end-stage kidney disease (ESKD) and impair patients' survival. The "treat-to-target" strategy, which aims at obtaining and maintaining remission or low disease activity of SLE to alleviate symptoms and prevent organ damage, also refers to the control of residual activity in the kidney. But damage in SLE can also come from treatments, and toxicities related to long-term use of treatments should be prevented. This may contribute to the frequent nonadherence in patients with SLE. The de-escalation or even weaning of treatments whenever possible, or "think-to-untreat" (T2U) strategy, is to be considered in patients with LN. This possibility of treatment weaning in LN was explored in retrospective cohorts, on the basis of long-term clinical remission. It was also proposed prospectively with a kidney-biopsy-based approach, combining clinical and pathologic remission to secure treatment weaning. The WIN-Lupus trial was the first randomized controlled trial comparing the continuation to the discontinuation of maintenance immunosuppressive therapy (IST) after 2 to 3 years in patients with LN in remission. It showed a higher risk of severe SLE flares in patients who discontinued treatment, but also a possibility of weaning without flare in some patients, who need to be better identified. We propose here a narrative review of the available literature on the weaning of treatment in LN and discuss how to secure a T2U strategy.
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Affiliation(s)
- Noémie Jourde-Chiche
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Mickaël Bobot
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Université, CERIMED, Marseille, France
| | - Stéphane Burtey
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Laurent Chiche
- Hôpital Européen de Marseille, Service de Médecine interne, Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, Paris, France
- Université Paris Cité, INSERM U1149, Paris, France
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Zucchi D, Cardelli C, Elefante E, Tani C, Mosca M. Treat-to-Target in Systemic Lupus Erythematosus: Reality or Pipe Dream. J Clin Med 2023; 12:jcm12093348. [PMID: 37176788 PMCID: PMC10178979 DOI: 10.3390/jcm12093348] [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: 04/03/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023] Open
Abstract
Treat-to-target is a therapeutic approach based on adjustments to treatment at set intervals in order to achieve well-defined, clinically relevant targets. This approach has been successfully applied to many chronic conditions, and in rheumatology promising results have emerged for rheumatoid arthritis. For systemic lupus erythematosus (SLE), defining the most meaningful treatment targets has been challenging, due to disease complexity and heterogeneity. Control of disease activity, the reduction of damage accrual and the patient's quality of life should be considered as the main targets in SLE, and several new drugs are emerging to achieve these targets. This review is focused on describing the target to achieve in SLE and the methods to do so, and it is also aimed at discussing if treat-to-target could be a promising approach also for this complex disease.
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Affiliation(s)
- Dina Zucchi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Chiara Cardelli
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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