1
|
Liu Y, Xie Y, Qin Y, Xie Q, Chen X. Control Groups in RCTs Supporting Approval of Drugs for Systemic Rheumatic Diseases, 2012-2022. JAMA Netw Open 2023; 6:e2344767. [PMID: 37991756 DOI: 10.1001/jamanetworkopen.2023.44767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
Importance Randomized clinical trials (RCTs) testing innovative drugs must strive to use optimal control groups to reflect the best available treatments. A comprehensive evaluation of the quality of control groups in pivotal RCTs supporting systemic rheumatic disease (SRD) drug approvals by the Food and Drug Administration (FDA) is lacking. Objective To examine the proportion of pivotal RCTs that used optimal control groups among RCTs supporting newly approved SRD drugs in the US over the past decade. Design, Setting, and Participants In this study, individual RCTs supporting SRD new drug approvals by the FDA between January 2012 and October 2022 were analyzed for design, study duration, control group, and primary end point. The quality of control groups was determined by comparison with published guidelines before and during the trial. Main Outcomes and Measures The primary measure was the proportion of RCTs using optimal control groups. Differences in response rate between investigating and control groups and the response rate of placebo control groups were also examined. Results Between January 2012 and October 2022, the FDA approved 44 SRD drugs, involving 65 pivotal RCTs. Overall, 16 RCTs used optimal control groups. In 55 trials, no active groups were used, and more than 80% of these trials were suboptimal (47 trials [85.5%]). Among 56 trials for systemic arthritis, 49 trials used suboptimal control groups, mainly placebo or dose-response controls (47 trials), with a few active controls (2 trials). Studies of other SRDs frequently used placebo or dose-response controls but were considered optimal controls (8 trials). There was significant improvement in response rates of investigating compared with placebo groups, with relative risk mostly exceeding 1.50 (range, 0.90; 95% CI, 0.69-1.17 for anifrolumab to 11.00; 95% CI, 2.69-44.96 for mepolizumab). In all placebo-controlled trials, the median (IQR) response rate in placebo groups was 26.0% (19.2%-32.3%). Conclusions and Relevance These findings suggest that the quality of control groups in RCTs leading to SRD drug approval needs improvement and that despite challenges in translating scientific theories to clinical scenarios, it is crucial to consistently prioritize efforts to promote appropriate control group selection to ensure the accurate assessment of innovative drug efficacy.
Collapse
Affiliation(s)
- Yang Liu
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
- Office of Clinical Trial Institute, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Yan Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yunhe Qin
- Pharmcube (Beijing) Co, Ltd, Beijing, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyuan Chen
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
- Office of Clinical Trial Institute, Beijing Tsinghua Changgung Hospital, Beijing, China
| |
Collapse
|
2
|
Bruce IN, van Vollenhoven RF, Morand EF, Furie RA, Manzi S, White WB, Abreu G, Tummala R. Sustained glucocorticoid tapering in the phase 3 trials of anifrolumab: a post-hoc analysis of the TULIP-1 and TULIP-2 trials. Rheumatology (Oxford) 2022; 62:1526-1534. [PMID: 36018235 PMCID: PMC10070065 DOI: 10.1093/rheumatology/keac491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/11/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Glucocorticoid sparing is a key priority for SLE management. We evaluated the effects of sustained glucocorticoid tapering in patients with SLE. METHODS This was a post hoc analysis of the randomized, placebo-controlled, 52-week phase 3 TULIP-1 and TULIP-2 trials of anifrolumab (300 mg intravenously once every four weeks for 48 weeks) plus standard therapy in patients with moderate to severe SLE. In a cohort of patients receiving glucocorticoids (prednisone or equivalent) 10 mg or more per day at baseline, we assessed changes in glucocorticoid dosage, patient-reported outcomes (PROs) and safety. Outcome measures were compared between sustained glucocorticoid taper responders (7.5 mg or less per day by Week 40 sustained through Week 52) and non-responders, regardless of treatment group, and between patients receiving anifrolumab or placebo. RESULTS Among the 726 patients in the TULIP trials, 375 patients received glucocorticoids 10 mg or more per day at baseline, and of these, 155 (41%) patients were sustained glucocorticoid taper responders. Compared with non-responders (n = 220), sustained glucocorticoid taper responders reduced their mean cumulative glucocorticoid dose by 32%, improved PRO scores, reduced blood pressure, and experienced fewer serious adverse events. Sustained glucocorticoid tapering was achieved by 51% (96/190) of patients receiving anifrolumab versus 32% (59/185) receiving placebo. Compared with placebo, more anifrolumab-treated patients achieved both sustained glucocorticoid taper and reduced overall disease activity (38% [72/190] vs 23% [33/185]). CONCLUSION Sustained glucocorticoid tapering is associated with clinical benefits. Anifrolumab treatment has potential to reduce disease activity and glucocorticoid exposure, a key goal of SLE management. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02446912 and NCT02446899.
Collapse
Affiliation(s)
- Ian N Bruce
- Centre for Epidemiology Versus Arthritis, The University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ronald F van Vollenhoven
- Amsterdam Rheumatology and Immunology Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, AUS
| | - Richard A Furie
- Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Susan Manzi
- Lupus Center of Excellence, Autoimmunity Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Gabriel Abreu
- BioPharmaceuticals R&D, AstraZeneca R&D, Gothenburg, Sweden
| | - Raj Tummala
- BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, MD, USA
| |
Collapse
|
3
|
Samões B, Zen M, Abelha-Aleixo J, Gatto M, Doria A. Caveats and pitfalls in defining low disease activity in systemic lupus erythematosus. Autoimmun Rev 2022; 21:103165. [PMID: 35931316 DOI: 10.1016/j.autrev.2022.103165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
The treat-to-target strategy has been recently suggested in the management of Systemic Lupus Erythematosus (SLE). Lupus Low Disease Activity State (LLDAS) and Definitions Of Remission In SLE (DORIS) remission were outlined as two concentric targets. The achievement of LLDAS was shown to be associated with lower frequency of SLE flare, decreased damage progression, better quality of life, and reduced mortality. In addition, LLDAS has successfully been tested in post-hoc analyses of a number of randomized controlled trials. However, it has been recently underlined that LLDAS includes a high proportion of patients in remission, raising the question if these endpoints are sufficiently distinct to consider their separation clinically relevant. Some studies suggest that the protective effect of LLDAS on damage might be due to the inclusion of patients who are in remission. Notably, clinical low disease activity (LDA) seems to be uncommon in SLE due to the relapsing-remitting pattern of the disease, in which low level of activity only occurs transiently. Moreover, since the domains included in LLDAS have several limitations, such as the use of a binomial disease activity index, the exclusion of some mild manifestations and the consideration of items subjected to variability (physician global assessment and glucocorticoids dose), not all patients in LDA are adequately represented by LLDAS.
Collapse
Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Joana Abelha-Aleixo
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| |
Collapse
|
4
|
Nikfar M, Malek Mahdavi A, Khabbazi A, Hajialilo M. Long-term remission in patients with systemic lupus erythematosus. Int J Clin Pract 2021; 75:e13909. [PMID: 33277751 DOI: 10.1111/ijcp.13909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/19/2020] [Accepted: 12/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Remission has been introduced as a desirable outcome and the primary target of treatment in systemic lupus erythematosus (SLE). The purpose of this study was to identify the number of patients in remission and the long-term outcome of the disease and their predictors. METHOD Of the 379 patients in our SLE Database, a total of 193 patients fulfilled the inclusion criteria. Remission was definition according to the definitions of remission in SLE. Three levels of remission were defined, including remission on-treatment, remission off-treatment and complete remission. In addition, we have defined a sustained remission for each level of remission in which the remission should last at least 5 years. RESULTS During a median follow-up of 96 months, remission on-treatment and off-treatment, and complete remission were obtained in 49.2%, 38.9% and 19.2% of patients, respectively. Predictors of remission on-treatment in multivariate regression analysis were adherence to therapy and remission induction during 6 months after treatment. Predictors of remission off-treatment were age ≥40 at the time of analysis and remission induction during 6 months after treatment. Poor outcome (SLE Damage Index ≥1) was observed in 28% of the patients. Age at disease onset <30, kidney and nervous system involvement and SLEDAI-2K ≥ 11 at the cohort entry were the risk factors of poor outcome in multivariate analysis. However, sustained remission on-treatment had a negative association with poor outcome. CONCLUSION Treatment with glucocorticoids, antimalarials, immunosuppressants and biologics in sequential or in combination may cause durable remission. Patients with durable remission have significantly lower organ damage.
Collapse
Affiliation(s)
- Mozhdeh Nikfar
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aida Malek Mahdavi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrzad Hajialilo
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
5
|
Malaga-Dieguez L, Trachtman H, Giusti R. Pulmonary Manifestations of Renal Disorders in Children. Pediatr Clin North Am 2021; 68:209-222. [PMID: 33228933 DOI: 10.1016/j.pcl.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The causes of kidney disease in pediatric patients are evenly divided between congenital abnormalities of the kidney and urinary tract and acquired disorders. Nearly 10% to 15% of adults in the United States have chronic kidney disease (CKD); there are no comparable data in children. Regardless of patient age, CKD is a systemic problem that affects every organ system, including the lung. We review the tests used to diagnose and evaluate kidney disease and the main clinical syndromes that are likely to be encountered to aid the pulmonology consultant who is asked to evaluate patients with kidney disease.
Collapse
Affiliation(s)
- Laura Malaga-Dieguez
- Division of Pediatric Nephrology, Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone, 550 First Avenue, New York, NY 10016, USA.
| | - Howard Trachtman
- Division of Pediatric Nephrology, Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone, 550 First Avenue, New York, NY 10016, USA
| | - Robert Giusti
- Division of Pediatric Pulmonology, Department of Pediatrics, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone, 550 First Avenue, New York, NY 10016, USA
| |
Collapse
|
6
|
Colombel JF, D’haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and Strategies to Support a Treat-to-target Approach in Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis 2020; 14:254-266. [PMID: 31403666 PMCID: PMC7008150 DOI: 10.1093/ecco-jcc/jjz131] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Management of Crohn's disease and ulcerative colitis has typically relied upon treatment intensification driven by symptoms alone. However, a 'treat-to-target' management approach may help to address underlying inflammation, minimise disease activity at early stages of inflammatory bowel disease, limit progression, and improve long-term outcomes. METHODS A systematic literature review was conducted to identify data relevant to a treat-to-target approach in inflammatory bowel disease, published between January 1, 2007 and May 15, 2017. RESULTS Consistent with recommendations of the Selecting Therapeutic Targets in Inflammatory Bowel Disease [STRIDE] working group, studies have investigated factors influencing the achievement of both endoscopic and histological mucosal healing and patient-level outcomes in inflammatory bowel disease [IBD]. Histological healing and biomarker levels have also been shown to be modifiable outcomes. Although there is a lack of prospectively derived evidence validating mucosal healing as a treatment target, data are emerging to suggest that targeting mucosal healing or inflammation rather than symptoms may be cost-effective in some settings. The review highlighted several strategies that may support the implementation of a treat-to-target approach in IBD. The prospective randomised CALM study demonstrated how tight control [whereby treatment decisions are based on close monitoring of inflammatory biomarkers] leads to improvements in endoscopic and clinical outcomes. The review also considered the influence of coordinated care from a multidisciplinary team and patient engagement with improved adherence, as well as the role of therapeutic drug monitoring in inflammatory bowel disease management. CONCLUSIONS A treat-to-target strategy may impact on disease progression and improve outcomes in inflammatory bowel disease. Prospective studies including long-term data are required to ensure that the most appropriate targets and strategies are identified.
Collapse
Affiliation(s)
- Jean-Frédéric Colombel
- Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D’haens
- Amsterdam University Medical Centers – Inflammatory Bowel Disease Unit, University of Amsterdam, Amsterdam, The Netherlands
| | - Wan-Ju Lee
- Global Gastroenterology, AbbVie, North Chicago, IL, USA
| | | | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Ruiz-Irastorza G, Ruiz-Estevez B, Lazaro E, Ruiz-Arruza I, Duffau P, Martin-Cascon M, Richez C, Ugarte A, Blanco P. Prolonged remission in SLE is possible by using reduced doses of prednisone: An observational study from the Lupus-Cruces and Lupus-Bordeaux inception cohorts. Autoimmun Rev 2019; 18:102359. [DOI: 10.1016/j.autrev.2019.102359] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 10/26/2022]
|
9
|
Ramirez GA, Canti V, Moiola L, Magnoni M, Rovere-Querini P, Coletto LA, Dagna L, Manfredi AA, Bozzolo EP. Performance of SLE responder index and lupus low disease activity state in real life: A prospective cohort study. Int J Rheum Dis 2019; 22:1752-1761. [PMID: 31379114 DOI: 10.1111/1756-185x.13663] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To prospectively assess the performance of the systemic lupus erythematosus (SLE) responder index (SRI) and the lupus low disease activity state (LLDAS) in a cohort-based, "real-life" clinical setting. METHODS One hundred and thirty-one consecutive patients with SLE were subdivided into two groups based on the need or not to escalate their immune suppressive treatment. Clinimetrics including physician global assessment scale (PGA), SLE Disease Activity Index 2000 (SLEDAI-2K), European Consensus Lupus Activity Measurement index (ECLAM) and British Isles Lupus Assessment Group index (BILAG) 2004 version were measured at baseline and at 6 and 12 months, together with laboratory data and treatment changes. LLDAS and SRI were calculated at each time point. RESULTS Lupus low disease activity state but not SRI-4 correlated with treatment de-escalation. Low disease activity attainment as estimated by LLDAS was more frequent in patients starting with lower SLEDAI-2K, whereas a decrease in SLEDAI score ≥ 4 points with < 0.3 increased PGA and no new grade A or more than one new grade B BILAG domains (SRI-4) was more frequent in patients with higher SLEDAI-2K and/or severe renal activity at baseline. Anti-DNA-positive patients were less likely to be in LLDAS at any time point. Serositis was associated with lack of LLDAS at baseline, but did not affect LLDAS achievement at 12 months. Normalizing complement levels heralded the achievement of LLDAS and SRI-4. CONCLUSION Lupus low disease activity state is a valuable tool for assessing response to treatment in the daily rheumatology practice. SRI might be less informative, at least in patients with low basal SLEDAI.
Collapse
Affiliation(s)
- Giuseppe A Ramirez
- Università Vita-Salute San Raffaele, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valentina Canti
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Lucia Moiola
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Marco Magnoni
- Cardiothoracic Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Patrizia Rovere-Querini
- Università Vita-Salute San Raffaele, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Lorenzo Dagna
- Università Vita-Salute San Raffaele, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Angelo A Manfredi
- Università Vita-Salute San Raffaele, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Enrica P Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| |
Collapse
|
10
|
How can we define low disease activity in systemic lupus erythematosus? Semin Arthritis Rheum 2018; 48:1035-1040. [PMID: 30415943 DOI: 10.1016/j.semarthrit.2018.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND In recent years, low disease activity emerged as a state that is associated with improved long-term outcomes in systemic lupus erythematosus (SLE). Our aim was to review the current concepts for low disease activity in SLE in order to serve as the basis of a future consensus for standardization. METHODS The PubMed database was searched for relevant articles from inception up to July 2018. Medical Subject Headings (MeSH terms) included "lupus" AND "low disease activity" OR "minimal disease activity". RESULTS Three different definitions of low disease activity in lupus have been proposed. Minimal disease activity (MDA) is defined as a clinical SLE Disease Activity Index 2000 (SLEDAI-2K)≤1 on antimalarials, immunosuppressives in standard doses and prednisone ≤5 mg/day. Low disease activity (LDA) allows for a clinical SLEDAI-2K≤2 maintained on antimalarials only. Lupus Low Disease Activity State (LLDAS) accepts a SLEDAI-2K≤4 with no activity from major organ systems, a Physician's Global Assessment of ≤1 with no new activity, prednisone dose ≤7.5 mg/day and standard doses of antimalarials, immunosuppressives and biologics. Active serology (anti-dsDNA and complement C3/C4) is not included in the MDA and LDA but counts towards disease activity in the LLDAS definition. All definitions were associated with less damage-accrual and mortality in the long-term that were comparable to those of clinical remission. CONCLUSIONS There is solid evidence that low disease activity is associated with improved outcomes in SLE and could serve as a therapeutic target in daily practice and clinical trials. Future research should focus on advancing a consensus for the best possible definition.
Collapse
|
11
|
Trentin F, Gatto M, Zen M, Larosa M, Maddalena L, Nalotto L, Saccon F, Zanatta E, Iaccarino L, Doria A. Effectiveness, Tolerability, and Safety of Belimumab in Patients with Refractory SLE: a Review of Observational Clinical-Practice-Based Studies. Clin Rev Allergy Immunol 2018; 54:331-343. [PMID: 29512034 PMCID: PMC6132773 DOI: 10.1007/s12016-018-8675-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To date, belimumab is the only biological drug approved for the treatment of patients with active refractory SLE. We compared and critically analyzed the results of 11 observational clinical-practice-based studies, conducted in SLE referral centers. Despite the differences in endpoints and follow-up duration, all studies remarked that belimumab provides additional benefits when used as an add-on to existing treatment, allowing a higher rate of patients to reach remission and to taper or discontinue corticosteroids. In the OBSErve studies, 2–9.6% of patients discontinued corticosteroids and 72–88.4% achieved a ≥ 20% improvement by physician’s judgment at 6 months. In Hui-Yuen’s study, 51% of patients attained response by simplified SRI at month 6. In Sthoeger’s study, 72.3% of patients discontinued corticosteroids and 69.4% achieved clinical remission by PGA after a median follow-up of 2.3 years. In the multicentric Italian study, 77 and 68.7% of patients reached SRI-4 response at months 6 and 12, respectively. In all the studies, disease activity indices decreased over time. Retention rates at 6, 9, and 12 months were 82–94.1, 61.2–83.3, and 56.7–79.2%, respectively. The main limitations of these studies include the lack of a control group, the short period of observation (6–24 months) and the lack of precise restrictions regarding concomitant medication management. This notwithstanding, these experiences provide a more realistic picture of real-life effectiveness of the drug compared with the randomized controlled clinical trials, where stringent inclusion/exclusion criteria and changes in background therapy could limit the inference of data to the routine clinical care.
Collapse
Affiliation(s)
- Francesca Trentin
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Mariele Gatto
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Margherita Zen
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | | | - Larosa Maddalena
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Linda Nalotto
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Francesca Saccon
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Elisabetta Zanatta
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Luca Iaccarino
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy.
| |
Collapse
|
12
|
Sebastiani GD, Prevete I, Iuliano A, Piga M, Iannone F, Coladonato L, Govoni M, Bortoluzzi A, Mosca M, Tani C, Doria A, Iaccarino L, Tincani A, Fredi M, Conti F, Spinelli FR, Galeazzi M, Bellisai F, Zanetti A, Carrara G, Scirè CA, Mathieu A. Early Lupus Project: one-year follow-up of an Italian cohort of patients with systemic lupus erythematosus of recent onset. Lupus 2018; 27:1479-1488. [DOI: 10.1177/0961203318777112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To describe the clinical and serological features of a prospectively followed cohort of early diagnosed systemic lupus erythematosus (SLE) patients during a one-year follow-up period. Methods SLE patients with disease duration less than 12 months were consecutively enrolled in a multicentre, prospective study. At study entry and then every 6 months, a large panel of data was recorded. Results Of 260 patients enrolled, 185 had at least 12 months of follow-up; of these, 84.3% were female, 92.4% were Caucasians. Mean diagnostic delay was about 20 months; higher values of European Consensus Lupus Activity Measurement (ECLAM) and of organs/systems involved were both associated with shorter diagnostic delay. Clinical and serological parameters improved after study entry. However, patients' quality of life deteriorated and cardiovascular risk factors significantly increased. About one-third of patients with active disease at study entry went into remission (ECLAM = 0). Negative predictors for remission were: oral ulcers, arthritis, low C4, anti-SSB (Ro) antibodies and therapy with mycophenolate. There was a widespread use of glucocorticoids both at baseline and during follow-up. Conclusion Clinical symptoms and serological parameters improve during the first period after diagnosis. However, patients’ quality of life deteriorates. The widespread use of glucocorticoids is probably the reason for the early significant increase of some cardiovascular risk factors.
Collapse
Affiliation(s)
- G D Sebastiani
- UOC Reumatologia, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - I Prevete
- UOC Reumatologia, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - A Iuliano
- UOC Reumatologia, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - M Piga
- Cattedra e Struttura Complessa di Reumatologia, Università degli Studi e AOU di Cagliari, Italy
| | - F Iannone
- Dipartimento Interdisciplinare di Medicina - Sezione di Reumatologia, Universita' di Bari, Italy
| | - L Coladonato
- Dipartimento Interdisciplinare di Medicina - Sezione di Reumatologia, Universita' di Bari, Italy
| | - M Govoni
- UO e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Italy
| | - A Bortoluzzi
- UO e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Italy
| | - M Mosca
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Italy
| | - C Tani
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Italy
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Italy
| | - L Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Italy
| | - A Tincani
- UOC Reumatologia e Immunologia Clinica, Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, ASST Spedali Civili – Brescia, Italy
| | - M Fredi
- UOC Reumatologia e Immunologia Clinica, Dipartimento di Scienze Cliniche e Sperimentali, Università degli Studi di Brescia, ASST Spedali Civili – Brescia, Italy
| | - F Conti
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy
| | - F R Spinelli
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Italy
| | - M Galeazzi
- UOC di Reumatologia, Azienda Ospedaliera Universitaria Senese, Italy
| | - F Bellisai
- UOC di Reumatologia, Azienda Ospedaliera Universitaria Senese, Italy
| | - A Zanetti
- Centro Studi SIR (Società Italiana di Reumatologia), Italy
| | - G Carrara
- Centro Studi SIR (Società Italiana di Reumatologia), Italy
| | - C A Scirè
- Centro Studi SIR (Società Italiana di Reumatologia), Italy
| | - A Mathieu
- Cattedra e Struttura Complessa di Reumatologia, Università degli Studi e AOU di Cagliari, Italy
| |
Collapse
|
13
|
Doria A, Gatto M, Iaccarino L, Sarzi-Puttini P. Controversies in Rheumatology and Autoimmunity: Approaching the truth by the discussion. Clin Exp Rheumatol 2018; 17:1-3. [DOI: 10.1016/j.autrev.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
|
14
|
Clinical predictors of response and discontinuation of belimumab in patients with systemic lupus erythematosus in real life setting. Results of a large, multicentric, nationwide study. J Autoimmun 2018; 86:1-8. [DOI: 10.1016/j.jaut.2017.09.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/06/2017] [Accepted: 09/11/2017] [Indexed: 12/21/2022]
|
15
|
Piga M, Floris A, Cappellazzo G, Chessa E, Congia M, Mathieu A, Cauli A. Failure to achieve lupus low disease activity state (LLDAS) six months after diagnosis is associated with early damage accrual in Caucasian patients with systemic lupus erythematosus. Arthritis Res Ther 2017; 19:247. [PMID: 29126432 PMCID: PMC5681839 DOI: 10.1186/s13075-017-1451-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background The aim was to assess the attainability and outcome of the lupus low disease activity state (LLDAS) in the early stages of systemic lupus erythematosus (SLE). Methods LLDAS prevalence was evaluated at 6 (T1) and 18 (T2) months after diagnosis and treatment initiation (T0) in a monocentric cohort of 107 (median disease duration 9.7 months) prospectively followed Caucasian patients with SLE. Reasons for failure to achieve LLDAS were also investigated. Multivariate models were built to identify factors associated with lack of LLDAS achievement and to investigate the relationship between LLDAS and Systemic Lupus International Collaboration Clinics (SLICC)/Damage Index (SDI) accrual. Results There were 47 (43.9%) patients in LLDAS at T1 and 48 (44.9%) at T2. The most frequent unmet LLDAS criterion was prednisolone dose >7.5 mg/day (83% of patients with no LLDAS at T1). Disease manifestations with the lowest remission rate during follow up were increased anti-double-stranded DNA (persistently present in 85.7% and 67.5% of cases at T1 and T2, respectively), low serum complement fractions (73.2% and 66.3%) and renal abnormalities (46.4% and 28.6%). Renal involvement at T0 was significantly associated with failure to achieve LLDAS both at T1 (OR 7.8, 95% CI 1.4–43.4; p = 0.019) and T2 (OR 3.9, 95% CI 1.4–10.6; p = 0.008). Presence of any organ damage (SDI ≥1) at T2 was significantly associated with lack of LLDAS at T1 (OR 5.0, 95% CI 1.5–16.6; p = 0.009) and older age at diagnosis (OR 1.05 per year, 95% CI 1.01–1.09; p = 0.020). Conclusion LLDAS is a promising treatment target in the early stages of SLE, being attainable and negatively associated with damage accrual, but it fit poorly to patients with renal involvement.
Collapse
Affiliation(s)
- Matteo Piga
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy.
| | - Alberto Floris
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| | - Giulia Cappellazzo
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| | - Elisabetta Chessa
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| | - Mattia Congia
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| | - Alessandro Mathieu
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| | - Alberto Cauli
- Chair of Rheumatology and Rheumatology Unit, University Clinic and AOU of Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
| |
Collapse
|
16
|
Wu B, Deshpande G, Gu T, Popelar B, Philbin M, Wan GJ. Demographics, treatment patterns, and healthcare utilization and cost of repository corticotropin injection in patients with systemic lupus erythematosus or rheumatoid arthritis. J Med Econ 2017; 20:1170-1177. [PMID: 28760047 DOI: 10.1080/13696998.2017.1362411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate healthcare resource utilization (HRU) and costs among patients who initiated repository corticotropin injection (RCI; H.P. Acthar Gel) treatment for rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). METHODS Patients aged ≥18 years with ≥2 diagnoses for either RA or SLE between July 1, 2006 and April 30, 2015 were identified in the HealthCore Integrated Research Database. Index RCI date was the earliest date of a medical or pharmacy claim for RCI after diagnosis. Baseline characteristics, pre- and post-initiation HRU and costs were assessed using descriptive statistics. RESULTS This study identified 180 RA patients (mean age = 60 years, 56% female) and 29 SLE patients (mean age = 45 years, 90% female) who initiated RCI. First RCI use averaged 7.1 and 22.6 months after the initial RA and SLE diagnosis, respectively. After RCI initiation, RA patients incurred significantly lower per-patient-per-month (PPPM) all-cause medical costs ($1,881 vs $682, p < .01) vs the pre-initiation period, driven by lower PPPM hospitalizations costs ($1,579 vs $503, p < .01). Overall PPPM healthcare costs were higher ($2,751 vs $5,487, p < .01) due to higher PPPM prescription costs ($869 vs $4,805, p < .01). Similarly, SLE patients had decreased PPPM hospitalization costs ($3,192 vs $799, p = .04) and increased PPPM prescription costs ($905 vs $7,443, p < .01) after initiating RCI; the difference in overall PPPM healthcare costs was not statistically significant likely, due to small sample size. CONCLUSION This study, across a heterogeneous population of variable disease duration, described clinical and healthcare utilization and costs of RA and SLE patients initiating RCI in a real-world setting. We observed that patients receiving RCI had lower utilization and costs for medical services in both disease populations, which partially offset the increased prescription costs by 30% and 37%. Future research is needed to explore factors associated with RCI initiation and its impact on long-term outcomes.
Collapse
Affiliation(s)
- Bingcao Wu
- a HealthCore, Inc. , Wilmington , DE , USA
| | | | - Tao Gu
- a HealthCore, Inc. , Wilmington , DE , USA
| | | | | | - George J Wan
- c Mallinckrodt Pharmaceuticals , Hampton , NJ , USA
| |
Collapse
|
17
|
Györi N, Giannakou I, Chatzidionysiou K, Magder L, van Vollenhoven RF, Petri M. Disease activity patterns over time in patients with SLE: analysis of the Hopkins Lupus Cohort. Lupus Sci Med 2017; 4:e000192. [PMID: 28243457 PMCID: PMC5307372 DOI: 10.1136/lupus-2016-000192] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe SLE disease activity patterns in the Hopkins Lupus Cohort. METHODS Disease activity was studied in 1886 patients followed-up for 1-28 years. Disease activity patterns were defined using (1) Physician Global Assessment (PGA) and (2) modified SLE Disease Activity Index (M-SLEDAI) as follows: long quiescent (LQ), M-SLEDAI=0/PGA=0 at all visits; relapsing-remitting (RR), periods of activity (M-SLEDAI>0/PGA>0) interspersed with inactivity (M-SLEDAI=0/PGA=0); chronic active (CA), M-SLEDAI>0/PGA>0 at all visits. The pattern of first 3 consecutive follow-up years was determined in 916 patients as: persistent LQ (pLQ), persistent RR (pRR) and persistent CA (pCA), LQ, RR and CA pattern in each of the 3 years, respectively; mixed, at least two different pattern types were identified. RESULTS The RR pattern accounted for the greatest proportion of follow-up time both by M-SLEDAI and PGA, representing 53.8% and 49.9% of total patient-years, respectively. The second most frequent pattern was LQ based on M-SLEDAI (30.7%) and CA based on PGA (40.4%). For the first 3-year intervals, the mixed pattern type was the most common (56.6%). The pRR was the second most frequent (M-SLEDAI 33.3%, PGA 26.5%), while pLQ (M-SLEDAI 6.4%, PGA 0.7%) and pCA were less frequent (M-SLEDAI 3.7%, PGA 16.3%). CONCLUSIONS The RR pattern was the most prevalent pattern. LQ was achieved in a subset of patients, using the M-SLEDAI. However, the PGA captured mild activity missed on the M-SLEDAI in these patients. Over a 3-year perspective, less than half of patients maintained their original pattern.
Collapse
Affiliation(s)
- Noémi Györi
- ClinTRID-Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - Ioanna Giannakou
- ClinTRID-Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - Katerina Chatzidionysiou
- ClinTRID-Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - Laurence Magder
- Division of Rheumatology , School of Medicine, Johns Hopkins University , Baltimore, MD , USA
| | - Ronald F van Vollenhoven
- ClinTRID-Unit for Clinical Therapy Research, Inflammatory Diseases, Department of Medicine , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - Michelle Petri
- Division of Rheumatology , School of Medicine, Johns Hopkins University , Baltimore, MD , USA
| |
Collapse
|
18
|
Iaccarino L, Bettio S, Reggia R, Zen M, Frassi M, Andreoli L, Gatto M, Piantoni S, Nalotto L, Franceschini F, Larosa M, Fredi M, Punzi L, Tincani A, Doria A. Effects of Belimumab on Flare Rate and Expected Damage Progression in Patients With Active Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2016; 69:115-123. [PMID: 27390293 DOI: 10.1002/acr.22971] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/23/2016] [Accepted: 06/21/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate effectiveness and safety of belimumab in patients with active systemic lupus erythematosus (SLE) in a clinical practice setting. METHODS Sixty-seven patients with active SLE, mean ± SD age 39.3 ± 10.2 years, from 2 Italian prospective cohorts were treated with belimumab (10 mg/kg on day 0, 14, 28, and then every 28 days) added to background therapy. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, the Disease Activity Score in 28 joints (DAS28), 24-hour proteinuria, the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) activity score, anti-double-stranded DNA (anti-dsDNA), C3 and C4 levels, and prednisone daily dose were recorded at baseline, month 3, 6, 9, 12, 18, and 24. Arthritis was subdivided into "classical" (CLP) and "rheumatoid-like"; skin manifestations into acute (ACLE), subacute (SCLE), and chronic. SLE flares, defined according to the SLEDAI Flare Index, were calculated before and after belimumab initiation. Adverse events were carefully evaluated during treatment. Statistics were performed by the SPSS package (version 21.0). RESULTS Mean ± SD followup was 16.2 ± 9.5 months. Main refractory manifestations treated with belimumab were musculoskeletal (37.3%), mucocutaneous (22.4%), and renal (23.9%). SLEDAI-2K, prednisone daily dose, anti-dsDNA, DAS28, CLASI, and 24-hour proteinuria decreased during treatment. DAS28 score decreased in patients with polyarthritis (P < 0.001), particularly in those with CLP (P < 0.001), and CLASI decreased in patients with skin manifestation (P = 0.003), either ACLE (P = 0.051) or SCLE (P = 0.047). Flare rate was lower 1 and 2 years after belimumab initiation than in the periods before (P = 0.001). Belimumab was well-tolerated and no damage accrual was observed after initiation. CONCLUSION Belimumab was effective and safe in a clinical practice setting; it decreased the number of flares and hindered damage progression in patients with active SLE.
Collapse
Affiliation(s)
| | | | | | | | - Micol Frassi
- Spedali Civili and University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Spedali Civili and University of Brescia, Brescia, Italy
| | | | | | | | | | | | - Micaela Fredi
- Spedali Civili and University of Brescia, Brescia, Italy
| | | | - Angela Tincani
- Spedali Civili and University of Brescia, Brescia, Italy
| | | |
Collapse
|
19
|
Giovannoni G, Butzkueven H, Dhib-Jalbut S, Hobart J, Kobelt G, Pepper G, Sormani MP, Thalheim C, Traboulsee A, Vollmer T. Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord 2016; 9 Suppl 1:S5-S48. [PMID: 27640924 DOI: 10.1016/j.msard.2016.07.003] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families. METHODS Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs). RESULTS Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models. CONCLUSIONS The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.
Collapse
Affiliation(s)
- Gavin Giovannoni
- Queen Mary University London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | - Suhayl Dhib-Jalbut
- Department of Neurology, RUTGERS-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
| | | | | | | | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Timothy Vollmer
- Department of Neurology, University of Colorado Denver, Aurora, CO, USA.
| |
Collapse
|
20
|
Gatto M, Saccon F, Zen M, Bettio S, Iaccarino L, Punzi L, Doria A. Success and failure of biological treatment in systemic lupus erythematosus: A critical analysis. J Autoimmun 2016; 74:94-105. [PMID: 27373904 DOI: 10.1016/j.jaut.2016.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 11/26/2022]
Abstract
Patients affected with systemic lupus erythematosus (SLE) still display increased mortality and decreased quality of life in respect to general population. The major determinant of poor long term prognosis is organ damage, which is predictive of more damage and death. Damage is in turn triggered by uncontrolled disease activity and especially by the long-standing corticosteroid use which often accompanies SLE patients over their disease course, owing both to the need of reaching disease remission and to the habit of keeping patients on a small steroid dose for an indefinite period of time. Hence, the need for new drugs and therapeutic strategies aiming at minimizing damage accrual through a better control of disease activity and a steroid-sparing potential is paramount. So far, however, the therapeutic strategy in SLE requires a multitarget approach which is not devoid of widespread immunesuppression. In fact, several studies have been carried out in recent years targeting both the adaptive and the innate immune system, the majority of which did not achieve their primary endpoint, being often divergent from successful clinical experience and thereby committing physician to off-label use of targeted therapies in face of refractory SLE manifestations. The study designs and the chosen endpoints were often blamed for inadequacy, being at least in part responsible for study failures. In this review, we go over major clinical trials conducted in SLE by analyzing any critical aspects related to study design, predefined endpoints and biological activity of novel compounds that may have hampered study outcome, despite the great effort of providing less toxic drugs within a targeted, pathogenic-based approach.
Collapse
Affiliation(s)
- Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Silvano Bettio
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Luca Iaccarino
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Leonardo Punzi
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35123, Padova, Italy.
| |
Collapse
|
21
|
Abstract
OPINION STATEMENT With the expanding armamentarium in IBD the current treatment targets can be reached. By optimally using our drugs we can avoid long-term complications in IBD. For this the therapeutic strategy has to be changed from a clinically driven approach to a target-driven strategy. Currently mucosal healing, normalization of biomarkers, histological healing, and healing on abdominal imaging are proposed targets. Correct phenotyping of the patient before initiation of therapy is mandatory. Once treatment is initiated a continuous re-evaluation with consequent adaptation of the treatment when goals are not (yet) reached is needed. Both escalation and de-escalation should be considered. Drug levels can be used as a guidance to reach these targets.
Collapse
Affiliation(s)
- Peter Bossuyt
- Department of Gastroenterology, University Hospitals Leuven, KULeuven-University of Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gastroenterology, Imelda GI Clinical Research Centre, Imelda ziekenhuis, Bonheiden, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, KULeuven-University of Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
22
|
Abstract
Though rare, childhood lupus is a disease with the potential to have serious short and long term effects in children. These effects are to do with the disease itself, organ damage consequent to ongoing inflammation and/or because of side effects of medications. As children have an early disease onset, accrual organ damage over the years and growth and puberty issues are important aspects of care. Thus it is essential to recognize the disease early, objectively assess the patient at regular intervals, treat to a target of remission and limit the use of steroids as far as possible. This review focuses on the elements that help identify these patients in the clinic, discusses the role of objective disease assessment and outlines management and co-morbidities in these patients.
Collapse
|
23
|
Benvenuti F, Gatto M, Larosa M, Iaccarino L, Punzi L, Doria A. Cardiovascular risk factors, burden of disease and preventive strategies in patients with systemic lupus erythematosus: a literature review. Expert Opin Drug Saf 2015. [PMID: 26212119 DOI: 10.1517/14740338.2015.1073259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Risk of developing cardiovascular disease (CVD) is increased in systemic lupus erythematosus (SLE) compared with the general population. Traditional risk factors cannot account for the totality of CV events and adequate prevention may be challenging. AREAS COVERED This review summarizes traditional and emerging risk factors of CVD in SLE patients and goes over potential pathogenic mechanisms involved in CVD development. Role of commonly used drugs and preventive strategies exploitable in everyday clinical practice are also discussed. EXPERT OPINION SLE-related risk factors involve both disease- and treatment-related features, including disease activity, disease phenotype, corticosteroid misuse and alterations of innate and adaptive immunity. Primary prevention is mandatory in management of lupus patients through appropriate disease control, corticosteroid tapering, use of antimalarials and eventually vitamin D supplementation.
Collapse
Affiliation(s)
- Francesco Benvenuti
- a 1 University of Padova, Division of Rheumatology, Department of Medicine , Via Giustiniani 2, 35128 Padova, Italy +390 498 212 202, +393 388 072 644 ; +390 498 212 191 ;
| | | | | | | | | | | |
Collapse
|
24
|
Zen M, Iaccarino L, Gatto M, Bettio S, Nalotto L, Ghirardello A, Punzi L, Doria A. Prolonged remission in Caucasian patients with SLE: prevalence and outcomes. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-207347] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AimTo assess the prevalence of prolonged remission in Caucasian patients affected with systemic lupus erythematosus (SLE) and its relationship with damage accrual.MethodsCaucasian patients diagnosed with SLE between 1990 and 2009 and quarterly seen from 2009 to 2013 were included in the study. We defined remission as prolonged when lasting ≥5 consecutive years. Three levels of remission were defined using the SLE Disease Activity Index-2000 (SLEDAI-2K): complete remission: no disease activity in corticosteroid-free and immunosuppressant-free patients; clinical remission off corticosteroids: serologically active clinical quiescent (SACQ) disease in corticosteroid-free patients and clinical remission on corticosteroids: SACQ disease in patients taking prednisone 1–5 mg/day. Damage was measured by the SLICC/American College of Rheumatology Damage Index (SDI).Results224 patients fulfilled inclusion criteria: 196 (87.5%) were women, mean±SD disease duration 11.2±6.8 years. During the 5-year follow-up, 16 patients (7.1%) achieved prolonged complete remission, 33 (14.7%) prolonged clinical remission off corticosteroids and 35 (15.6%) prolonged clinical remission on corticosteroids. At the multivariate analysis, vasculitis (OR 4.95), glomerulonephritis (OR 2.38) and haematological manifestations (OR 2.19) over the patients’ disease course were associated with an unremitted disease. SDI increased more frequently in unremitted (72/140, 51.4%) than in remitted patients (22/84, 26.2%; p=0.001); SDI median increase was higher in unremitted than in remitted patients: 1 (0–3) vs 0 (0–2), respectively (p<0.001). At multivariate analysis, unremitted disease (OR 2.52) and high-dose corticosteroid intake (OR 2.35) were risk factors for damage accrual.ConclusionsThirty-seven percent of our Caucasian patients achieved a prolonged remission, which was associated with a better outcome in terms of damage accrual.
Collapse
|