Early damage as measured by the SLICC/ACR damage index is a predictor of mortality in systemic lupus erythematosus

The aim of this study was to determine whether early damage accrued in SLE as measured by the SLICC/ACR Damage Index predicts mortality in an inception cohort of lupus patients that have been followed prospectively in a single centre. SLE patients from the University of Toronto Lupus Clinic presenting within 1 y of their diagnosis prior to 1988 were included. This enabled all patients to be potentially followed for at least 10 y. Yearly SLICC/ACR Damage Index scores were determined for each patient. Early damage was defined as a score > or = 1 and no damage as a score of 0 at the initial assessment. Log rank test was used to compare the survival experience between those with and without damage, with all patients being censored at 10 y. Two-hundred and sixty-three patients were identified in this inception cohort who were followed for 10 y. One-hundred and ninety patients (72%) had a SLICC/ACR Damage Index score of 0 (no damage) while 73 patients (28%) had at least one SLICC/ACR Damage Index item scored (early damage). Twenty-five percent of lupus patients who exhibited damage at their first SLICC/ACR Damage Index assessment died within 10 y of their illness as compared to only 7.3% who had no early damage (log rank P-value = 0.0002). SLE patients who died within 10 y were more likely to have renal damage (P = 0.013), and a trend toward more cardiovascular disease (P = 0.056), compared to patients who were alive. Early damage as reflected by the initial SLICC/ACR Damage Index is associated with a higher rate of mortality.

Comparison of radiological severity in psoriatic arthritis and rheumatoid arthritis

OBJECTIVE

To compare the radiological severity of patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA).

METHODS

Patients were identified from the University of Toronto PsA and RA databases. Using the earliest available radiographs, each RA patient was matched to a single PsA patient on the basis of sex, age, and disease duration. Two rheumatologists blinded to the patient's diagnosis scored the radiographs using the modified Steinbrocker method.

RESULTS

PsA and RA groups were similar with respect to demographics as well as the use of disease modifying antirheumatic medications. No significant difference in Steinbrocker score for the hands and feet or the hands only was noted. Patients with RA had a higher radiological score in the feet. The 2 groups were similar in the number of joints with significant radiological damage (Steinbrocker 3 and 4). CONCLUSION; Overall the radiological severity in the hands and feet of patients with PsA was comparable to that of patients with RA.

Vascular events in hypertensive patients with systemic lupus erythematosus

Our purpose was to examine prospectively the relationship between systemic hypertension and vascular events in patients with SLE. SLE patients followed in the University of Toronto Lupus Clinic presenting between 1980 and 1988 and within one year of their diagnosis of SLE were identified. Standard definitions were used for hypertension and for all vascular events (MI, angina, CVA, PVD). The presence of traditional CAD risk factors, along with disease- and therapy-related risk factors for the development of vascular disease, were compared in the hypertensive and normotensive group. A multivariate logistic regression was performed to determine the best predictor of a vascular event. One hundred and fifty patients were identified in our inception cohort [75 hypertensive (50%) and 75 (50%) normotensive]. Seventeen hypertensive patients (22.7%) had at least one vascular event as compared to six (8.0%) normotensive patients (p = 0.022). The vascular events included 7 with CAD, 5 with CVA, and 5 with PVD in the hypertensive group while in the normotensive group 3 patients developed CAD, 2 CVA and 1 PVD. Fifteen deaths were recorded in the hypertensive group as compared to eight deaths in the non-hypertensive groups (P = 0.09). The groups were comparable with respect to associated risk factors, except for higher frequency of hypercholesterolemia (P = 0.003), azotemia (P = 0.001) and corticosteroid use (P = 0.038) in the hypertension group. In a multivariate analysis the best predictor of a vascular event was hypercholesterolemia (OR 6.9, 95% CI 2.4-24.8, P < 0.001). We conclude that systemic hypertension is associated with an increased frequency of vascular events in SLE. This is best explained by its association with hypercholesterolemia.

Spinal hyperostosis--a rare skeletal manifestation of psoriasis vulgaris

A 28-year-old woman with uncomplicated psoriasis vulgaris presented with spinal hyperostosis and osteitis. The absence of peripheral arthritis, sacroiliitis, and diffuse idiopathic skeletal hyperostosis (DISH) raised the possibility that the spinal lesion was an extracutaneous manifestation of psoriasis. We review the association between uncomplicated psoriasis vulgaris and skeletal involvement.

Effect of antimalarial agents on the fasting lipid profile in systemic lupus erythematosus

OBJECTIVE

To ascertain the relative effect of antimalarial (AM) agents on fasting lipid fractions in patients with systemic lupus erythematosus (SLE).

METHODS

The study was cross sectional including all patients with SLE who were seen in our lupus clinic with fasting lipid profiles measured as part of evaluation from November 1995 to March 1999.

RESULTS

A total of 123 patients with a mean age of 45.3 years and mean disease duration 13.4 years were studied; 73.2% were taking prednisone with a mean +/- SD dose of 10.9 +/- 9.2 mg/day, 48.0% were taking AM, and 30.8% were taking both. In the entire group, patients taking AM had a 12.5% lower total cholesterol (TC) (5.11 +/- 1.27 vs 5.84 +/- 1.23; p = 0.002), 22.1% lower very low density lipid-cholesterol (VLDL-C) (0.66 +/- 0.40 vs 0.85 +/- 0.39; p = 0.01), and 15.7% lower LDL-C (3.01 +/- 1.14 vs 3.58 +/- 1.10; p = 0.007). For patients taking prednisone, those taking concomitant AM (n = 38) had significantly lower TC (5.26 +/- 1.30 vs 5.99 +/- 1.29; p = 0.01), VLDL-C (0.65 +/- 0.39 vs 0.85 +/- 0.41; p = 0.02), and LDL-C (3.05 +/- 1.20 vs 3.69 +/- 1.09; p = 0.01) than those without AM (n = 48). For patients taking < or = 10 mg/day prednisone, TC (4.69 +/- 0.88 vs 5.74 +/- 1.20; p < 0.001), VLDL-C (0.61 +/- 0.37 vs 0.83 +/- 0.44; p = 0.05), and LDL-C (2.57 +/- 0.76 vs 3.49 +/- 1.04; p < 0.001) were still lower in patients with concomitant AM (n = 22) than those without AM (n = 36).

CONCLUSION

TC, VLDL-C, and LDL-C levels were significantly lower in patients taking AM, including patients taking concomitant prednisone. Thus AM may have beneficial effects in SLE in addition to disease suppression.

Probing for genes in seronegative spondyloarthropathy

Seronegative spondyloarthropathies are a group of disorders characterized by inflammation of the spine, sacroiliac joints, and peripheral arthritis along with various characteristic extra-articular features. Their pathogenesis and immunogenetics have not yet been fully elucidated. Ankylosing Spondylitis (AS) is probably the best studied of these disease. It has now been 27 years since the association of human leukocyte antigen (HLA) B27 and AS has been demonstrated. Since then, a plethora of association studies and linkage studies unequivocally demonstrate that genetic determinants within or near the major histocompatible complex (MHC) are critical to the etiology of AS. Surprisingly though, the total MHC contribution to AS has been estimated at only 30%. In this review, we highlight the genetic basis of AS as the prototypical chronic axial arthritis, and discuss the rationale and approach in searching for non-HLA linked genes.

Comparison of clinical and immunogenetic features in familial versus sporadic psoriatic arthritis

OBJECTIVE

To compare patients with familial versus sporadic psoriatic arthritis (PsA) with respect to clinical, radiological and immunogenetic features.

METHODS

All patients were identified from the University of Toronto Psoriatic Arthritis Clinic. Familial and sporadic PsA were distinguished based on the proband's self-reported history. The probands were compared at presentation to clinic with respect to: demographic information, age of onset of psoriasis and inflammatory arthritis, disease activity, disease damage, laboratory variables, functional class and HLA antigens. The two groups were compared using a univariate analysis.

RESULTS

In total 407 patients were included. Thirty-six patients (8.8%) were eliminated as they reported a family history of arthritis in the absence of psoriasis. Of the remaining 371 patients, 150 patients reported a positive family of either PsA or psoriasis. 221 patients (54.2%) had no family history of psoriatic arthritis, psoriasis, or "arthritis". The familial group were younger at presentation to clinic (p = 0.003), had an earlier age of onset of psoriasis (p = 0.001) and inflammatory arthritis (p = 0.001) and were more likely to be receiving treatment (p = 0.001). The mean number of actively inflamed joints was higher in the sporadic group (p = 0.035), along with a higher frequency of rheumatoid factor positivity (p = 0.04). Only the age of onset variables and medication use retained significance after correction for multiple comparisons.

CONCLUSIONS

In comparing probands with familial versus sporadic PsA, we noted a marked difference in the age of onset of psoriasis and inflammatory arthritis, along with other differences in several clinical variables. These differences may be helpful in identifying PsA patients with a stronger genetic predisposition.

Contribution of traditional risk factors to coronary artery disease in patients with systemic lupus erythematosus

OBJECTIVE

Several factors have been implicated in the high prevalence of premature coronary artery disease (CAD) in patients with systemic lupus erythematosus (SLE). We hypothesize that variables independent of traditional risk factors contribute significantly to the development of CAD in SLE. We investigated the relative contribution of traditional risk factors in SLE patients with CAD compared to non-SLE patients with premature CAD.

METHODS

An age matched retrospective cohort analysis. The prevalence of traditional cardiovascular risk factors (hypertension, hypercholesterolemia, diabetes, smoking, family history) in patients with SLE who developed CAD during the course of their illness was compared to a group of age matched non-SLE subjects with premature CAD. Sexes were analyzed separately using Fisher's exact test and unpaired t tests.

RESULTS

Thirty-five patients with SLE (27 women, 8 men) with definite ischemic heart disease were identified along with 397 non-SLE subjects (83 women, 314 men). In women with SLE the mean number of CAD risk factors per cardiac event was 2.0 +/- 0.77 versus 2.90 +/- 1.19 for the comparison group (p = 0.0008). In men with SLE the mean number of CAD risk factors was 1.87 +/- 0.83 versus 2.73 +/- 0.99 in the comparison group (p = 0.016).

CONCLUSION

SLE patients with a cardiac event have fewer traditional risk factors than non-SLE patients with premature CAD. Thus premature CAD in SLE cannot be attributed solely to an excess of traditional risk factors.

IDDM9 and a locus for rheumatoid arthritis on chromosome 3q appear to be distinct

Markers near a locus for type 1 diabetes on chromosome 3q22-q25 (IDDM9) demonstrate linkage to rheumatoid arthritis, however it is not clear whether these two loci overlap. Sex-specific linkage analysis may be of interest for rheumatoid arthritis on chromosome 3q since linkage of type 1 diabetes to IDDM9 derives predominantly from affected female sibpairs, and rheumatoid arthritis is more common in females than males. Using data from a recent genome scan for rheumatoid arthritis and sex-specific linkage analysis we show that linkage of rheumatoid arthritis to chromosome 3q peaks approximately 30 cM centromeric to IDDM9. Furthermore, there is no evidence for linkage to IDDM9 in females with rheumatoid arthritis.

Excessive paternal transmission in psoriatic arthritis

OBJECTIVE

The differential expression of a disease according to the sex of the disease-transmitting parent has been demonstrated in several autoimmune disorders. The purpose of the present study was to determine whether there are differences in the transmission and expression of psoriatic arthritis (PsA) that are dependent on the sex of the affected parent.

METHODS

All probands (patients with PsA) were identified from among the patients attending the University of Toronto Psoriatic Arthritis Clinic. A self-reported family history of psoriasis or PsA was noted for each proband. Differences in parental and offspring transmission with respect to the proband were evaluated. In addition, the expression of PsA according to the sex of the affected parent was assessed at the time of the proband's presentation to the clinic.

RESULTS

Ninety-five probands had affected parents: 62 (65%) had an affected father, and 33 (35%) had an affected mother. Thus, the proportion of paternal transmission (0.65) was significantly greater than was expected (0.5) (P = 0.001). Twelve of 74 offspring from male probands (16.2%) were affected with psoriasis or PsA, as compared with 9 of 108 offspring from female probands (8.3%) (P = 0.10). Probands whose fathers were affected had a higher frequency of skin lesions prior to arthritis (P = 0.047), an erythrocyte sedimentation rate > 15 mm/hour (P = 0.044), and a lower incidence of rheumatoid factor (P = 0.044). No differences were noted with respect to age at the onset of psoriasis or PsA, the severity of the PsA, or the frequency of HLA antigens.

CONCLUSION

There appears to be excessive paternal transmission in PsA. Further clinical confirmation and elucidation of its genetic basis is warranted.

The cholesterol lowering effect of antimalarial drugs is enhanced in patients with lupus taking corticosteroid drugs

OBJECTIVE

To examine the relationship between antimalarial therapy and total cholesterol in patients with systemic lupus erythematosus (SLE) with or without steroid therapy.

METHODS

Retrospective study for the University of Toronto Lupus Clinic database between 1976 and 1997. The effects of antimalarials on random total cholesterol levels were assessed in the following situations: patients not receiving steroids (part I) that either initiated or discontinued antimalarials; patients receiving steroids (part II) that were either on a stable dose or initiating antimalarials; and patients initiating steroids with or without antimalarials (part III). Paired t test, Fisher's exact test, and 2 way analysis of variance were used when appropriate.

RESULTS

Initiation of antimalarials reduced the baseline total cholesterol by 4.1 % at 3 months in 53 patients (p = 0.020) and by 0.6% at 6 months in 30 patients (p = NS), while the cessation of antimalarials increased the total cholesterol by 3.6% at 3 months in 38 patients (p = NS) and 5.4% at 6 months in 22 patients (p = NS). In 181 patients taking steroids and antimalarials, the mean total cholesterol was 11% less than for 201 patients receiving a comparable dose of steroids alone (p = 0.0023). Initiation of antimalarials on a stable dose of steroids reduced the total cholesterol by 11.3% at 3 months in 29 patients (p = 0.0002) and 9.4% at 6 months in 20 patients (p = 0.004). For patients initiating steroids, the percentage increase in cholesterol was lower in those taking antimalarials compared to patients without antimalarial therapy (p = 0.0149).

CONCLUSION

Antimalarials lower total cholesterol in patients receiving steroids and may minimize steroid induced hypercholesterolemia.

The use of sulfasalazine in psoriatic arthritis: a clinic experience

OBJECTIVE

To assess the tolerability of sulfasalazine in a clinic setting and determine its longterm effectiveness with respect to articular disease and prevention of radiographic progression in patients with psoriatic arthritis (PsA).

METHODS

Patients who were given sulfasalazine during their attendance at the University of Toronto Psoriatic Arthritis Clinic were enrolled in the study. For patients that were able to tolerate sulfasalazine for at least 3 months a matched control was identified who did not receive sulfasalazine. The primary outcome measures were the tolerability of sulfasalazine, clinical response of the actively inflamed joints at 6 and 12 months, and the change in radiographic score at 24 months.

RESULTS

Thirty-six patients received sulfasalazine. Fourteen of 16 patients discontinued sulfasalazine due to one or more side effects occurring within 3 months of treatment initiation. For the remaining 20 patients, a 50% reduction in actively inflamed joint count was noted in 7/20 patients at 6 months and 11/15 patients at 12 months, compared to 7/19 patients in the control group at 6 months and 10/20 patients at 12 months. The mean change in the radiographic score at 24 months between the 2 groups was not statistically significant.

CONCLUSION

Sulfasalazine was not well tolerated in patients with PsA in our clinic. For those able to tolerate sulfasalazine, there was no evidence of a treatment effect with respect to articular involvement. In addition, sulfasalazine does not appear to halt radiographic progression in PsA.

Smoking interferes with efficacy of antimalarial therapy in cutaneous lupus

OBJECTIVE

There have been occasional reports of patients with refractory cutaneous lupus improving after cessation of cigarette smoking. It has been hypothesized that the effects of cigarette smoking on hepatic cytochrome P450 induction can alter the metabolism of antimalarials. Our objective was to determine the role of smoking in the efficacy of antimalarial therapy in cutaneous lupus.

METHODS

A retrospective cohort study from the University of Toronto Lupus Clinic. Patients with either acute discoid or subacute cutaneous lupus (SACL) who received antimalarial therapy for their cutaneous lesions were selected. The smoking group consisted of regular smokers, while the nonsmoking group consisted of individuals who never smoked during the study period. The primary outcome measure was the complete resolution of the cutaneous lesion at 6 and 12 months of antimalarial therapy. Secondary outcome measures included the mean steroid dose and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score. Analysis included descriptive statistics and Fisher's exact test.

RESULTS

Seventeen smokers (9 with discoid lupus, 5 SACL, 3 both) and 19 nonsmokers (11 discoid, 6 SACL, 2 both) were identified. The cutaneous eruption resolved completely in 3/17 smokers versus 9/17 nonsmokers after 6 months of antimalarial therapy (p < 0.035) and 3/16 smokers and 9/17 nonsmokers at 12 months (p < 0.046). There was no significant change in the mean steroid dose or SLEDAI in either group.

CONCLUSION

Smoking appears to decrease the efficacy of antimalarial therapy in cutaneous lupus. The interaction between smoking and the efficacy of antimalarials in a variety of SLE presentations should be investigated further.

Clinical predictors of fetal outcome in systemic lupus erythematosus

OBJECTIVE

To describe the fetal outcomes in systemic lupus erythematosus (SLE) in the University of Toronto Lupus Clinic Cohort and to identify clinical or serological factors that would predict pregnancy loss and poor fetal outcome.

METHODS

Seventy-three patients with 141 pregnancies were identified between 1970 and 1995. Patients were evaluated before pregnancy and at each trimester with a standardized protocol. Analysis included descriptive statistics and univariate and multivariate analysis.

RESULTS

There were 86 (60.1%) live births, 34 (23.8%) spontaneous abortions, 3 (2.2%) stillbirths, and 20 (14%) therapeutic abortions. Of live births, 21 (24.4%) were premature babies, 6 (7.9%) intrauterine growth retardation, 3 (3.5%) had neonatal lupus, 2 (2.3%) congenital malformations, and there were 2 (2.3%) perinatal deaths. Maternal renal disease was the only statistically significant predictor for fetal loss (p<0.0 12) and hypertension for poor fetal outcome (p<0.024) using univariate analysis.

CONCLUSION

Most lupus pregnancies do well, but there is an increased incidence of adverse fetal outcome. Predictive factors for adverse fetal outcome include maternal renal disease and hypertension.

Coexistence of Fabry's disease and systemic lupus erythematosus

This report describes a case of a female with systemic lupus erythematosus, who was subsequently diagnosed with Fabry's disease. Due to similarities in the organs involved by these two multisystem disorders, difficulties were encountered in establishing a prompt diagnosis of Fabry's disease. That and subsequent management of this patient are discussed. A literature review of the coexistence of the two disorders along with the potential pathogenic mechanisms explaining this association are explored.

Radiological assessment in psoriatic arthritis

Our objective was to compare the reliability and responsiveness of the original Steinbrocker's (OS), our modified Steinbrocker's (MS) and Larsen's (L) radiological scoring methods for detecting radiological change in psoriatic arthritis over time. Two sets of radiographs of the hands and feet at least 2 yr apart were selected from 68 patients. Films were randomly presented and scored independently by a rheumatologist (DDG) and a radiologist (DS), in a blinded fashion using all methods. The index of reliability was the intraclass coefficient (ICC) and the responsiveness was assessed using plots and regression analyses. All three radiological scoring methods have excellent interobserver and good intra-observer reliability. L and MS are equally responsive and superior to OS in detecting change in joint damage over time. Thus, the L or MS radiological scoring methods can be used to monitor disease progression in psoriatic arthritis.

Efficacy and tolerability of methotrexate in antimalarial resistant lupus arthritis

OBJECTIVE

To determine the efficacy and tolerability of low dose intermittent methotrexate (MTX) in antimalarial resistant lupus arthritis.

METHODS

Retrospective cohort study from the University of Toronto Lupus Clinic. Seventeen patients receiving MTX for persistently active arthritis, despite a previous therapeutic trial of antimalarial therapy, were identified. Seventeen control patients were selected who had active arthritis despite 6 months of treatment with an antimalarial agent. The primary outcome measure was a reduction in actively inflamed joint count of at least 60% over 6 months. Secondary outcome measures were the reduction in steroid dose and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and tolerability of MTX.

RESULTS

Baseline characteristics including sex, race, age at diagnosis, and concomitant use of other medications were similar. Patients in the MTX group had a higher mean joint count than the control group at baseline (p = 0.003). After 6 months, 15/17 patients in the MTX group showed at least a 60% improvement in the joint count compared to only 2/17 for the control group (p < 0.001). The mean daily prednisone dose fell by 35 and 27% in the MTX and control groups, respectively (p = NS). A mean SLEDAI reduction of 0.76 was obtained in the MTX group, compared to an increase of 2.05 in the control group (p = 0.03). Over a mean followup period of 3.5 years, toxicity leading to termination was infrequent, as only 2 patients discontinued MTX due to a side effect.

CONCLUSION

Methotrexate appears to be effective in the treatment of antimalarial resistant lupus arthritis and is well tolerated.

Cytotoxic therapy in systemic lupus erythematosus. Experience from a single center

The present survey of cytotoxic therapy from a single large lupus clinic has shown that approximately 33% of the patients have received cytotoxic therapy at some point in their course. These agents were initiated for a variety of manifestations, with renal manifestations being the major indication, accounting for 28.2% of the cytotoxic agents used. Other common indications for initiation of cytotoxic therapy included steroid sparing (18.4%), global flare (12.5%), neurologic manifestations (11.4%), and musculoskeletal (8.6%). Azathioprine, methotrexate, and cyclophosphamide accounted for 98% of all cytotoxic agents used. Azathioprine was the most frequently used cytotoxic drug (70%), followed by methotrexate (21.5%) and cyclophosphamide (9.4%). Cytotoxic agents were used sequentially in 12.5% of patients and in combination in 4.2% of the patients. Overall, the use of cytotoxic therapy appears to be beneficial in reducing global disease activity, as the mean SLEDAI fell by 2.59 (33%) over 6 months of cytotoxic therapy, and the mean steroid dose was reduced by 37% over the same time period. There was also an improvement in most organ-specific indications with the use of cytotoxic agents. Overall the cytotoxic agents were well tolerated, with 17% of the courses being discontinued due to a side effect. Cytopenia was the most common side effect necessitating discontinuation of cytotoxic agents.