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Anderson EW, Sansone M, Shah B, Kline M, Franchin G, Aranow C, Mackay M. Addition of constitutional symptoms to the SLEDAI-2K improves overall disease activity assessment: A pilot study. Lupus 2024; 33:840-850. [PMID: 38664230 DOI: 10.1177/09612033241249785] [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: 05/31/2024]
Abstract
OBJECTIVE Constitutional symptoms (fatigue, lymphadenopathy, and weight loss) are not included in the SLE disease activity index-2000 (SLEDAI-2K). In this pilot study, we assessed the concurrent and construct validity of a revised SLEDAI-2K (SLED-R) that included these symptoms with the original SLEDAI-2K (SLED-O), using the physician global assessment of disease activity (PGA) as the reference. METHODS Our revised SLED-R substituted the SLED-O's fever descriptor with a constitutional descriptor that included fever, fatigue, lymphadenopathy, and/or weight loss. SLED-O, SLED-R, PGA and patient global assessment (PtGA) scores were collected prospectively. Bland-Altman correlations for repeated measures were calculated and Meng's z-test was used to compare correlations between dependent and overlapping correlation coefficients. Associations between constitutional symptoms and disease activity measures were analyzed using Mann-Whitney U, Kruskal-Wallis, Chi-square tests and repeated measures correlations. RESULTS 1123 SLED-O, SLED-R, PGA, and 1066 PtGA were collected in 239 subjects. The new descriptor was scored in 45 subjects (18.8%) and 92 instances (8.1%), while the original descriptor, fever, was scored in only 4 subjects (1.7%) and 5 instances (0.4%). Mean SLED-O, PGA and PtGA scores were higher when the constitutional descriptor was scored versus not (p < .001). The correlation between SLED-R and PGA was marginally higher than between SLED-O and PGA (p < .001). Fatigue contributed most to this increase (p = .001) and associated with both higher PGA and PtGA scores (p < .001). Mean SLED-O and PGA scores were higher when ≥1 constitutional symptom(s) were scored versus not (p < .002). Correlations between PGA and PtGA when the new descriptor was scored versus not were similar (p = .860). The frequency of concordance between PGA and PtGA was lower when the new descriptor was scored (55%) versus not (72.5%), with PGA > PtGA when the new descriptor was scored (p < .001). CONCLUSION The addition of constitutional symptoms to SLEDAI-2K, particularly fatigue, resulted in a marginal increase in its correlation with PGA, and new constitutional symptoms associated with higher SLED-O and PGA scores. As fatigue is subjective and difficult to attribute to SLE, its validity and inter-rater reliability in scoring remains uncertain. The clinical utility of SLED-R remains unclear, and further studies of its validity and reliability are needed.
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Affiliation(s)
- Erik W Anderson
- Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Marissa Sansone
- Divison of Rheumatology, Jersey City Medical Center, Jersey City, NJ, United States
| | - Bhakti Shah
- Division of Rheumatology, Northwell Health, Manhasset, NY, United States
| | - Myriam Kline
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, NY, United States
| | - Giovanni Franchin
- Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Cynthia Aranow
- Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Meggan Mackay
- Institute of Molecular Medicine, The Feinstein Institutes for Medical Research, Manhasset, NY, United States
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Barber MRW, Ugarte-Gil MF, Hanly JG, Urowitz MB, St-Pierre Y, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey-Goldman R, Manzi S, Jönsen A, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Pons-Estel BA, Cardwell FS, Alarcón GS, Clarke AE. Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2024:ard-2024-225613. [PMID: 38754981 DOI: 10.1136/ard-2024-225613] [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: 01/31/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES This study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort. METHODS Patients from 31 centres in 10 countries were enrolled within 15 months of diagnosis and assessed annually. Five mutually exclusive disease activity states (DAS) were defined as (1) remission off-treatment: clinical (c) SLEDAI-2K=0, without prednisone/immunosuppressants; (2) remission on-treatment: cSLEDAI-2K=0, prednisone ≤5 mg/day and/or maintenance immunosuppressants; (3) LDA-Toronto Cohort (TC): cSLEDAI-2K≤2, without prednisone/immunosuppressants; (4) modified lupus LDA state (mLLDAS): SLEDAI-2K≤4, no activity in major organs/systems, no new activity, prednisone ≤7.5 mg/day and/or maintenance immunosuppressants and (5) active: all remaining assessments.At each assessment, patients were stratified into the most stringent DAS fulfilled and the proportion of time in a DAS since cohort entry was determined. Annual DCs/ICs (2021 Canadian dollars) were based on healthcare use and lost workforce/non-workforce productivity over the preceding year.The association between the proportion of time in a DAS and annual DC/IC was examined through multivariable random-effects linear regressions. RESULTS 1692 patients were followed a mean of 9.7 years; 49.0% of assessments were active. Remission/LDA (per 25% increase in time in a remission/LDA state vs active) were associated with lower annual DC/IC: remission off-treatment (DC -$C1372; IC -$C2507), remission on-treatment (DC -$C973; IC -$C2604,) LDA-TC (DC -$C1158) and mLLDAS (DC -$C1040). There were no cost differences between remission/LDA states. CONCLUSIONS Our data suggest that systemic lupus erythematosus patients who achieve remission, both off and on-therapy, and reductions in disease activity incur lower costs than those experiencing persistent disease activity.
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Affiliation(s)
- Megan R W Barber
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Manuel Francisco Ugarte-Gil
- Grupo Peruano de Estudio de Enfermedades Autoinmunes Sistémicas, Universidad Cientifica del Sur, Lima, Peru
- Rheumatology, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray B Urowitz
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Diseases, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Krembil Research Institute, Toronto, Ontario, Canada
| | - Yvan St-Pierre
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Caroline Gordon
- Rheumatology Research Group, Birmingham University Medical School, Birmingham, UK
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea (the Republic of)
- Hanyang Institute of Bioscience and Biotechnology, Seoul, Korea (the Republic of)
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Jorge Sanchez-Guerrero
- University Health Network, Toronto, Ontario, Canada
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sasha Bernatsky
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Daniel J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Department of Medicine, University College London, London, UK
| | - Joan T Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Paul R Fortin
- Centre ARThrite, CHU de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Dafna D Gladman
- Krembil Research Institute, Toronto, Ontario, Canada
- Lupus Program, Centre for Prognosis in The Rheumatic Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- The Kellgren Centre for Rheumatology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Michelle Petri
- Division of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Mary Anne Dooley
- Thurston Arthritis Research Centre, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Susan Manzi
- Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | | | | | - Cynthia Aranow
- The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | - S Sam Lim
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul University, Istanbul Medical Faculty, Capa, Istanbul, Turkey
| | | | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anca Askanase
- Division of Rheumatology, Columbia University Lupus Center, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autonmunes y Reumáticas, Rosario, Argentina
| | - Francesca S Cardwell
- Geography & Environmental Management, University of Waterloo, Waterloo, Ontario, Canada
| | - Graciela S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama, Birmingham, Alabama, USA
| | - Ann E Clarke
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Rogers JL, Clowse MEB, McKenna K, Starling S, Swezey T, Molokwu N, Corneli A, Pisetsky DS, Sun K, Criscione-Schreiber LG, Sadun RE, Maheswaranathan M, Burshell D, Doss J, Eudy AM. Patient and Physician Perspectives of Systemic Lupus Erythematosus Flare: A Qualitative Study. J Rheumatol 2024; 51:488-494. [PMID: 38101916 PMCID: PMC11065621 DOI: 10.3899/jrheum.2023-0721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) flares are associated with increased damage and decreased health-related quality of life. We hypothesized that there is discordance between physicians' and patients' views of SLE flare. In this study, we aimed to explore patient and physician descriptions of SLE flares. METHODS We conducted a qualitative descriptive study using in-depth interviews with a purposeful sample of patients with SLE (who met 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria) and practicing rheumatologists. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. RESULTS Forty-two patient participants with SLE, representing a range of SLE activity, completed interviews. The majority described flare symptoms as joint pain, fatigue, and skin issues lasting several days. Few included objective signs or laboratory measures, when available, as features of flare. We interviewed 13 rheumatologists from 10 academic and 3 community settings. The majority defined flare as increased or worsening SLE disease activity, with slightly more than half requiring objective findings. Around half of the rheumatologists included fatigue, pain, or other patient-reported symptoms. CONCLUSION Patients and physicians described flare differently. Participants with SLE perceived flares as several days of fatigue, pain, and skin issues. Providers defined flares as periods of increased clinical SLE activity. Our findings suggest the current definition of flare may be insufficient to integrate both perceptions. Further study is needed to understand the pathophysiology of patient flares and the best way to incorporate patients' perspectives into clinical assessments.
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Affiliation(s)
- Jennifer L Rogers
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Megan E B Clowse
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Kevin McKenna
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Summer Starling
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Teresa Swezey
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Nneka Molokwu
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Amy Corneli
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - David S Pisetsky
- D.S. Pisetsky, MD, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine, and Durham VA Medical Center, Durham, North Carolina, USA
| | - Kai Sun
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Lisa G Criscione-Schreiber
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Rebecca E Sadun
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Mithu Maheswaranathan
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Dana Burshell
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Jayanth Doss
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Amanda M Eudy
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine;
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Pisetsky DS. Unique Interplay Between Antinuclear Antibodies and Nuclear Molecules in the Pathogenesis of Systemic Lupus Erythematosus. Arthritis Rheumatol 2024. [PMID: 38622070 DOI: 10.1002/art.42863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/19/2024] [Accepted: 04/11/2024] [Indexed: 04/17/2024]
Abstract
Systemic lupus erythematosus (SLE) is a prototypic autoimmune disease that primarily affects young women and causes a wide range of inflammatory manifestations. The hallmark of SLE is the production of antibodies to components of the cell nucleus (antinuclear antibodies [ANAs]). These antibodies can bind to DNA, RNA, and protein complexes with nucleic acids. Among ANAs, antibodies to DNA (anti-DNA) are markers for classification and disease activity, waxing and waning disease activity in many patients. In the blood, anti-DNA antibodies can bind to DNA to form immune complexes with two distinct roles in pathogenesis: (1) renal deposition to provoke nephritis and (2) stimulation of cytokine production following uptake into innate immune cells and interaction with internal nucleic acid sensors. These sensors are part of an internal host defense system in the cell cytoplasm that can respond to DNA from infecting organisms; during cell stress, DNA from nuclear and mitochondrial sources can also trigger these sensors. The formation of immune complexes requires a source of extracellular DNA in an immunologically accessible form. As shown in in vivo and in vitro systems, extracellular DNA can emerge from dead and dying cells in both a free and a particulate form. Neutrophils undergoing the process of NETosis can release DNA in mesh-like structures called neutrophil extracellular traps. In SLE, therefore, the combination of ANAs and immunologically active DNA can create new structures that can promote inflammation throughout the body as well as drive organ inflammation and damage.
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Affiliation(s)
- David S Pisetsky
- Duke University Medical Center and Durham Veterans Administration Medical Center, Durham, North Carolina
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5
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Rogers JL, Clowse MEB, Pisetsky DS, Criscione-Schreiber LG, Sun K, Sadun RE, Maheswaranathan M, Burshell DR, Doss J, Eudy AM. Evaluation of Type 2 SLE symptoms in patients with a range of lupus nephritis activity. Clin Rheumatol 2024; 43:1319-1326. [PMID: 38409491 DOI: 10.1007/s10067-024-06909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/12/2024] [Accepted: 02/11/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Type 2 systemic lupus erythematosus (SLE) symptoms, including fatigue, fibromyalgia, and brain fog, contribute to poor health-related quality of life (HRQoL) in patients with lupus. To test the hypothesis that Type 1 (classical inflammatory lupus) activity is associated with Type 2 SLE activity, we characterized the features of Type 2 SLE in patients with a range of lupus nephritis (LN) activity. METHODS This was a cross-sectional study of SLE patients [American College of Rheumatology (ACR) 1997 or Systemic Lupus International Collaborating Clinics (SLICC) 2012 classification criteria] from June 2018 to March 2020. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and the Polysymptomatic Distress Scale. Patients were divided into groups based on their renal status. Active nephritis was defined using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) lupus nephritis parameter. Differences across groups were analyzed by Fisher's exact test and ANOVA. RESULTS In this cohort of 244 patients (93% female, mean age 43 years, 58% Black), 10% had active nephritis, 35% had historical nephritis, and 55% never had nephritis (non-nephritis). Active nephritis and non-nephritis patients had a similar burden of Type 2 SLE symptoms, despite a difference in Type 1 SLE activity. Patients with active nephritis had higher Type 2 PGA (Physician Global Assessment) scores and reported more Type 2 SLE symptoms than inactive nephritis patients. Patients with inactive nephritis had the lowest Type 2 SLE activity. CONCLUSIONS While Type 2 SLE symptoms are common in SLE, our findings suggest that patients with active nephritis experience significant Type 2 SLE symptoms that may be ameliorated as nephritis improves. We also observed that non-nephritis patients had a similar burden of Type 2 SLE symptoms as patients with active nephritis, despite having on average lower Type 1 SLE activity. Therefore, the etiology of Type 2 SLE symptoms is likely multifactorial and may be driven by inflammatory and non-inflammatory biopsychosocial factors. Key Points • Patients with active nephritis experienced significant Type 2 symptoms that may be ameliorated as nephritis improves. • Non-nephritis patients had a similar burden of Type 2 SLE symptoms as patients with active nephritis, despite having on average lower Type 1 SLE activity. • Because etiology of Type 2 SLE symptoms is likely multifactorial and may be driven by inflammatory and non-inflammatory biopsychosocial factors.
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Affiliation(s)
- Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA.
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
- Durham VA Medical Center, Durham, NC, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Kai Sun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Dana R Burshell
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
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Corbitt K, Carlucci PM, Cohen B, Masson M, Saxena A, Belmont HM, Tseng C, Barbour KE, Gold H, Buyon J, Izmirly P. Clinical and Serologic Phenotyping and Damage Indices in Patients With Systemic Lupus Erythematosus With and Without Fibromyalgia. ACR Open Rheumatol 2024; 6:172-178. [PMID: 38196183 PMCID: PMC11016564 DOI: 10.1002/acr2.11641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVE Given fibromyalgia (FM) frequently co-occurs with autoimmune disease, this study was initiated to objectively evaluate FM in a multiracial/ethnic cohort of patients with systemic lupus erythematosus (SLE). METHODS Patients with SLE were screened for FM using the 2016 FM classification criteria during an in-person rheumatologist visit. We evaluated hybrid Safety of Estrogens in Lupus National Assessment (SELENA)-SLE Disease Activity Index (SLEDAI) scores, SLE classification criteria, and Systemic Lupus International Collaborating Clinics damage index. We compared patients with and without FM and if differences were present, compared patients with FM with patients with non-FM related chronic pain. RESULTS 316 patients with SLE completed the FM questionnaire. 55 (17.4%) met criteria for FM. The racial composition of patients with FM differed from those without FM (P = 0.023), driven by fewer Asian patients having FM. There was no difference in SLE disease duration, SELENA-SLEDAI score, or active serologies. There was more active arthritis in the FM group (16.4%) versus the non-FM group (1.9%) (P < 0.001). The Widespread Pain Index and Symptom Severity Score did not correlate with degree of SLE activity (r = -0.016; 0.107) among patients with FM or non-FM chronic pain (r = 0.009; -0.024). Regarding criteria, patients with FM had less nephritis and more malar rash. Systemic Lupus International Collaborating Clinics damage index did not differ between groups. CONCLUSION Except for arthritis, patients with SLE with FM are not otherwise clinically or serologically distinguishable from those without FM, and Widespread Pain Index and Symptom Severity Score indices do not correlate with SLEDAI. These observations support the importance of further understanding the underlying biology of FM in SLE.
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Eudy AM, Clowse MEB, Corneli A, McKenna K, Pisetsky DS, Maheswaranathan M, Burshell D, Doss J, Sun K, Sadun RE, Criscione-Schreiber LG, Rogers JL. The Type 1 & 2 systemic lupus erythematosus model: Perspectives of people living with systemic lupus erythematosus. Lupus 2024; 33:266-272. [PMID: 38238905 PMCID: PMC11034781 DOI: 10.1177/09612033241228343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
OBJECTIVE In the new Type 1 & 2 model for systemic lupus erythematosus (SLE), Type 1 SLE represents classic inflammatory manifestations, such as arthritis, while Type 2 SLE encompasses symptoms such as pain and fatigue where the relationship to inflammation is less clear. The objective of this study was to interview individuals living with SLE to determine the content and face validity of the Type 1 & 2 SLE model. METHODS We conducted a qualitative study using semi-structured interviews with a purposeful sample of participants who met classification criteria for SLE. Participants were asked to describe their experiences with Type 1 & 2 SLE symptoms and treatments, and they indicated if and how their personal experiences aligned with the Type 1 & 2 SLE model. All interviews were audio-recorded and transcribed; applied thematic analysis identified the most frequent and salient themes. RESULTS We interviewed 42 participants with SLE. Type 2 SLE symptoms, such as pain and fatigue, were very common, with almost all participants experiencing some Type 2 symptoms at some point during their disease course. Participants described Type 1 SLE symptoms as being acute flares and life-threatening and Type 2 SLE symptoms as "everyday lupus" that affected their daily lives and were a dominant part of their SLE disease experience. Most participants stated they want their rheumatologists to discuss Type 2 symptoms during clinical appointments in order to address their full symptom experience. CONCLUSION We demonstrated content and face validity of the Type 1 & 2 SLE model with people living with SLE. Participants in our study largely understood the model and felt it accurately reflected their experience living with SLE. Type 2 SLE symptoms are very common in individuals with SLE and impact patients' quality of life. Using the model to address Type 2 SLE symptoms allows the rheumatologist to incorporate the patient's perspective and provide patient-centered care.
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Affiliation(s)
- Amanda M. Eudy
- Department of Medicine, Duke University School of Medicine
| | | | - Amy Corneli
- Department of Medicine, Duke University School of Medicine
- Department of Population Health Sciences, Duke University School of Medicine
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine
| | - David S. Pisetsky
- Department of Medicine, Duke University School of Medicine
- Durham VA Medical Center
| | | | - Dana Burshell
- Department of Medicine, Duke University School of Medicine
| | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine
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Rekvig OP. The greatest contribution to medical science is the transformation from studying symptoms to studying their causes-the unrelenting legacy of Robert Koch and Louis Pasteur-and a causality perspective to approach a definition of SLE. Front Immunol 2024; 15:1346619. [PMID: 38361929 PMCID: PMC10867267 DOI: 10.3389/fimmu.2024.1346619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
The basic initiative related to this study is derived from the fact that systemic lupus erythematosus (SLE) is a unique and fertile system science subject. We are, however, still far from understanding its nature. It may be fair to indicate that we are spending more time and resources on studying the complexity of classified SLE than studying the validity of classification criteria. This study represents a theoretical analysis of current instinctual SLE classification criteria based on "the causality principle." The discussion has its basis on the radical scientific traditions introduced by Robert Koch and Louis Pasteur. They announced significant changes in our thinking of disease etiology through the implementation of the modern version of "the causality principle." They influenced all aspects of today's medical concepts and research: the transformation of medical science from studies of symptoms to study their causes, relevant for monosymptomatic diseases as for syndromes. Their studies focused on bacteria as causes of infectious diseases and on how the immune system adapts to control and prevent contagious spreading. This is the most significant paradigm shift in the modern history of medicine and resulted in radical changes in our view of the immune system. They described acquired post-infection immunity and active immunization by antigen-specific vaccines. The paradigm "transformation" has a great theoretical impact also on current studies of autoimmune diseases like SLE: symptoms and their cause(s). In this study, the evolution of SLE classification and diagnostic criteria is discussed from "the causality principle" perspective, and if contemporary SLE classification criteria are as useful as believed today for SLE research. This skepticism is based on the fact that classification criteria are not selected based on cogent causal strategies. The SLE classification criteria do not harmonize with Koch's and Pasteur's causality principle paradigms and not with Witebsky's Koch-derived postulates for autoimmune and infectious diseases. It is not established whether the classification criteria can separate SLE as a "one disease entity" from "SLE-like non-SLE disorders"-the latter in terms of SLE imitations. This is discussed here in terms of weight, rank, and impact of the classification criteria: Do they all originate from "one basic causal etiology"? Probably not.
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Affiliation(s)
- Ole Petter Rekvig
- Section for Autoimmunity, Fürst Medical Laboratory, Oslo, Norway
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, Boletis J, Bruce IN, Cervera R, Doria A, Dörner T, Furie RA, Gladman DD, Houssiau FA, Inês LS, Jayne D, Kouloumas M, Kovács L, Mok CC, Morand EF, Moroni G, Mosca M, Mucke J, Mukhtyar CB, Nagy G, Navarra S, Parodis I, Pego-Reigosa JM, Petri M, Pons-Estel BA, Schneider M, Smolen JS, Svenungsson E, Tanaka Y, Tektonidou MG, Teng YO, Tincani A, Vital EM, van Vollenhoven RF, Wincup C, Bertsias G, Boumpas DT. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024; 83:15-29. [PMID: 37827694 DOI: 10.1136/ard-2023-224762] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence. METHODS An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item. RESULTS The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease. CONCLUSION The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York City, New York, USA
| | - Dafna D Gladman
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frederic A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Luís Sousa Inês
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; School of Health Sciences, Universidade da Beira Interior, Covilha, Portugal
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - László Kovács
- Department of Rheumatology and Immunology, Faculty of Medicine, University of Szeged, Hungary
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gabriella Moroni
- Department of Biomedical Sciences Humanitas University, Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Johanna Mucke
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - György Nagy
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sandra Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - José M Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) - VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Joint Academic Rheumatology Program, Athens, Greece
| | - Yk Onno Teng
- Centre of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Greece, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece, Medical School, University of Cyprus, Nicosia, Cyprus
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Sun K, Eudy AM, Harris N, Pisetsky DS, Criscione-Schreiber LG, Sadun RE, Doss J, Clowse MEB, Rogers JL. Using PROMIS-29 to determine symptom burdens in the context of the Type 1 and 2 systemic lupus erythematosus (SLE) model: a cross sectional study. J Patient Rep Outcomes 2023; 7:136. [PMID: 38127169 PMCID: PMC10739689 DOI: 10.1186/s41687-023-00678-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE To account for heterogeneity in systemic lupus erythematosus (SLE) and bridge discrepancies between patient- and physician-perceived SLE activity, we developed the Type 1 and 2 SLE model. We examined PROMIS-29 scores, a composite patient-reported outcome (PRO) measure, through the lens of the model. METHODS Patients completed PROMIS-29 and the polysymptomatic distress scale (PSD). Rheumatologists completed the SLE disease activity index (SLEDAI), and physician's global assessments (PGAs) for Type 1 and 2 SLE. We defined Type 1 SLE using SLEDAI, Type 1 PGA, and active nephritis, and Type 2 SLE using PSD and Type 2 PGA. We compared PROMIS-29 T-scores among Type 1 and 2 SLE groups and explored whether PROMIS-29 can predict Type 1 and 2 SLE activity. RESULTS Compared to the general population, patients with isolated Type 1 SLE reported greater pain and physical dysfunction but less depression and improved social functions; patients with high Type 2 SLE (irrespective of Type 1 activity) reported high levels of pain, fatigue, and social and physical limitations. Patients with minimal Type 1 and 2 SLE had less depression and greater physical functioning with other domains similar to national norms. PROMIS-29 predicted Type 2 but not Type 1 SLE activity. CONCLUSION PROMIS-29 similarities in patients with high Type 2 SLE, with and without active Type 1 SLE, demonstrate the challenges of using PROs to assess SLE inflammation. In conjunction with the Type 1 and 2 SLE model, however, PROMIS-29 identified distinct symptom patterns, suggesting that the model may help clinicians interpret PROs.
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Affiliation(s)
- Kai Sun
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA.
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Nathaniel Harris
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
- Durham VA Medical Center, Durham, NC, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
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11
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Clowse MEB, Rogers JL, Coles T, Pisetsky DS, Criscione-Schreiber LG, Burshell D, Doss J, Sadun RE, Sun K, Maheswaranathan M, Eudy AM. Development and psychometric evaluation of a physician global assessment for type 2 systemic lupus erythematosus symptoms. Lupus Sci Med 2023; 10:e001016. [PMID: 38105242 PMCID: PMC10729218 DOI: 10.1136/lupus-2023-001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Manifestations of SLE can be categorised as type 1 (classic signs and symptoms of SLE) or type 2 (fatigue, widespread pain and brain fog with an unclear relationship to inflammation). While measures of type 1 SLE activity exist, most current physician-reported measures do not encompass type 2 SLE manifestations. To better evaluate type 2 SLE symptoms, we developed and psychometrically evaluated a physician-reported measure of type 2 symptoms, the Type 2 Physician Global Assessment ('Type 2 PGA'). METHODS AND ANALYSIS The Type 2 PGA was developed and evaluated by six rheumatologists practising in the same academic lupus clinic. The study began with a roundtable discussion to establish consensus guidelines for scoring the Type 2 PGA. Following the roundtable, the Type 2 PGA was psychometrically evaluated using data prospectively collected from 263 patients with SLE enrolled in the Duke Lupus Registry. RESULTS There was strong intra-rater and inter-rater reliability (intraclass correlation coefficient=0.83), indicating the Type 2 PGA scores were consistent within a rheumatologist and across rheumatologists. The Type 2 PGA was correlated with patient-reported symptoms of polysymptomatic distress (r=0.76), fatigue (r=0.68), cognitive dysfunction (r=0.63), waking unrefreshed (r=0.62) and forgetfulness (r=0.60), and weakly correlated with the Type 1 PGA and the Systemic Lupus Erythematosus Disease Activity Index. CONCLUSION The Type 2 PGA performed well as a physician-reported measure of type 2 SLE symptoms. The incorporation of the Type 2 PGA into a routine rheumatology visit may improve patient care by bringing the provider's attention to certain symptoms not well represented in conventional measures of disease activity.
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Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Theresa Coles
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dana Burshell
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
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Rekvig OP. SLE classification criteria: Is "The causality principle" integrated and operative - and do the molecular and genetical network, on which criteria depend on, support the definition of SLE as "a one disease entity" - A theoretical discussion. Autoimmun Rev 2023; 22:103470. [PMID: 37884202 DOI: 10.1016/j.autrev.2023.103470] [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: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
Molecular and cellular aspects of the autoimmune pathophysiology in SLE is linked to the "The causality principle". SLE Classification Criteria identify per definition disease measures (here: synonymous with classification criteria), but not diagnostic criteria within a classical framework. These two mostly theoretical criteria collections represent a salient conflict between phenomenology and the causality principle - between disease measures and molecular interactions that promote such measures, in other words their cause(s). Essentially, each criterion evolves from immunogenic and inflammatory signals - some are interconnected, some are not. Disparate signals instigated by disparate causes. These may promote clinically heterogenous SLE cohorts with respect to organ affection, autoimmunity, and disease course. There is today no concise measures or arguments that settle whether SLE cohorts evolve from one decisive etiological factor (homogenous cohorts), or if disparate patho-biological factors promote SLE (heterogenous cohorts). Current SLE cohorts are not ideal substrates to serve as study objects if the research aims are to describe etiology, and molecular interactions that cause - and link - primary and secondary pathophysiological events together - events that account for early and progressive SLE. We have to develop SLE criteria allowing us to identify definable categories of SLE in order to describe etiology, pathophysiology and diagnostic criteria of delimitated SLE versions. In this regard, the causality principle is central to define dominant etiologies of individual SLE categories, and subsequent and consequent down-stream diagnostic disease measures. In this sense, we may whether we like it or not identify different SLE categories like "genuine SLE" and "SLE-like non-SLE" syndromes. Many aspects of this problem are thoroughly discussed in this study.
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Affiliation(s)
- Ole Petter Rekvig
- Fürst Medical Laboratory, Oslo, Norway; Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
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13
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Elefante E, Cornet A, Andersen J, Somers A, Mosca M. The communication GAP between patients and clinicians and the importance of patient reported outcomes in Systemic Lupus Erythematosus. Best Pract Res Clin Rheumatol 2023; 37:101939. [PMID: 38485601 DOI: 10.1016/j.berh.2024.101939] [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: 05/31/2023] [Accepted: 02/20/2024] [Indexed: 06/23/2024]
Abstract
Systemic Lupus Erythematosus (SLE) imposes a great burden on the lives of patients. Patients' and physicians' concerns about the disease diverge considerably. Physicians focus on controlling disease activity to prevent damage accrual, while patients focus on symptoms that impact on Health-Related Quality of Life (HRQoL). We explored the physicians' and patients' perspective and the potential role of Patient Reported Outcomes (PROs). Physicians are aware of the theoretical usefulness of PROs to collect information deriving from the patients' perspective. However, they often do not know how to interpret and use these questionnaires in a real shared therapeutic strategy. For the patients, it's important to be seen as a whole person with a true consideration of how they feel and function. Strategies to help bridge the communication gap could include: better use of time during visits, preparing for the consultation, a more understandable lay language used by the doctor, a dedicated nurse.
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Affiliation(s)
- Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, Italy
| | | | | | | | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Pisana, Italy.
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Barraclough M, Erdman L, Diaz-Martinez JP, Knight A, Bingham K, Su J, Kakvan M, Grajales CM, Tartaglia MC, Ruttan L, Wither J, Choi MY, Bonilla D, Appenzeller S, Parker B, Goldenberg A, Katz P, Beaton D, Green R, Bruce IN, Touma Z. Systemic lupus erythematosus phenotypes formed from machine learning with a specific focus on cognitive impairment. Rheumatology (Oxford) 2023; 62:3610-3618. [PMID: 36394258 PMCID: PMC10629781 DOI: 10.1093/rheumatology/keac653] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVE To phenotype SLE based on symptom burden (disease damage, system involvement and patient reported outcomes), with a specific focus on objective and subjective cognitive function. METHODS SLE patients ages 18-65 years underwent objective cognitive assessment using the ACR Neuropsychological Battery (ACR-NB) and data were collected on demographic and clinical variables, disease burden/activity, health-related quality of life (HRQoL), depression, anxiety, fatigue and perceived cognitive deficits. Similarity network fusion (SNF) was used to identify patient subtypes. Differences between the subtypes were evaluated using Kruskal-Wallis and χ2 tests. RESULTS Of the 238 patients, 90% were female, with a mean age of 41 years (s.d. 12) and a disease duration of 14 years (s.d. 10) at the study visit. The SNF analysis defined two subtypes (A and B) with distinct patterns in objective and subjective cognitive function, disease burden/damage, HRQoL, anxiety and depression. Subtype A performed worst on all significantly different tests of objective cognitive function (P < 0.03) compared with subtype B. Subtype A also had greater levels of subjective cognitive function (P < 0.001), disease burden/damage (P < 0.04), HRQoL (P < 0.001) and psychiatric measures (P < 0.001) compared with subtype B. CONCLUSION This study demonstrates the complexity of cognitive impairment (CI) in SLE and that individual, multifactorial phenotypes exist. Those with greater disease burden, from SLE-specific factors or other factors associated with chronic conditions, report poorer cognitive functioning and perform worse on objective cognitive measures. By exploring different ways of phenotyping SLE we may better define CI in SLE. Ultimately this will aid our understanding of personalized CI trajectories and identification of appropriate treatments.
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Affiliation(s)
- Michelle Barraclough
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Lauren Erdman
- Genetics and Genome Biology, Department of Computer Science, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, University of Toronto, Toronto, ON, Canada
| | - Juan Pablo Diaz-Martinez
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Andrea Knight
- Division of Rheumatology, Hospital for Sick Children, Toronto, ON, Canada
| | - Kathleen Bingham
- Centre for Mental Health, University Health Network, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jiandong Su
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Mahta Kakvan
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Carolina Muñoz Grajales
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Joan Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dennisse Bonilla
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Ben Parker
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Anna Goldenberg
- Genetics and Genome Biology, Department of Computer Science, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, University of Toronto, Toronto, ON, Canada
| | - Patricia Katz
- University of California, San Francisco, Novato, CA, USA
| | - Dorcas Beaton
- Institute for Work and Health, University of Toronto, Toronto, ON, Canada
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Zahi Touma
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
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15
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Murphy AE, Minhas D, Clauw DJ, Lee YC. Identifying and Managing Nociplastic Pain in Individuals With Rheumatic Diseases: A Narrative Review. Arthritis Care Res (Hoboken) 2023; 75:2215-2222. [PMID: 36785994 DOI: 10.1002/acr.25104] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023]
Abstract
Chronic pain is a burdensome and prevalent symptom in individuals with rheumatic disease. The International Association for the Study of Pain classifies pain into 3 descriptive categories: nociceptive, neuropathic, and nociplastic. These categories are intended to provide information about the mechanisms underlying the pain, which can then serve as targets for drug or non-drug treatments. This review describes the 3 types of pain as they relate to patients seen by rheumatology health care providers. The focus is on identifying individuals with nociplastic pain, which can either occur in isolation as in fibromyalgia, or as a comorbidity in individuals with primary autoimmune conditions, such as rheumatoid arthritis and systemic lupus erythematosus. Practical information about how rheumatology health care providers can approach and manage chronic pain is also provided.
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Affiliation(s)
| | - Deeba Minhas
- University of Michigan Medical School, Ann Arbor
| | | | - Yvonne C Lee
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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16
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Escoda T, Jourde-Chiche N, Granel B, Cornec D, Chiche L. Complex relationships of type 2 and type 1 symptoms across various systemic autoimmune diseases. Autoimmun Rev 2023; 22:103390. [PMID: 37463611 DOI: 10.1016/j.autrev.2023.103390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/14/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Thomas Escoda
- Service de Médecine Interne, Hôpital Européen, Marseille, France.
| | | | - Brigitte Granel
- Service de Médecine Interne, Hôpital Nord, Aix Marseille Université, Marseille, France
| | - Divi Cornec
- Service de Rhumatologie, Hôpital de la Cavale Blanche, Brest, France
| | - Laurent Chiche
- Service de Médecine Interne, Hôpital Européen, Marseille, France
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17
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Katz P, Patterson SL, DeQuattro K, Lanata CM, Barbour KE, Greenlund KJ, Gordon C, Criswell LA, Dall’Era M, Yazdany J. The association of trauma with self-reported flares and disease activity in systemic lupus erythematosus (SLE). Rheumatology (Oxford) 2023; 62:2780-2788. [PMID: 36477308 PMCID: PMC10544732 DOI: 10.1093/rheumatology/keac690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Trauma has been linked to incident SLE, but its relationship with SLE disease activity is unknown. This analysis examines associations between trauma exposures and patient-reported SLE disease activity and flares. METHODS Data were from the California Lupus Epidemiology Study (CLUES). Flares were self-reported as any flare and, of those, flares accompanied by medical care (hospitalization or physician contact). The Systemic Lupus Activity Questionnaire (SLAQ) assessed disease activity. The Brief Trauma Questionnaire (BTQ) assessed all historical trauma exposures. The Adverse Childhood Experiences (ACEs) questionnaire was available for a subset. Multivariable regression analyses (n = 252) examined whether trauma exposure was associated with flares or SLAQ controlling for age, sex, poverty, race/ethnicity, comorbidities, perceived stress, disease duration and self-reported disease damage. RESULTS Excluding exposure to serious illness, 63.4% reported ≥1 trauma exposure. Any traumatic event, excluding illness, doubled the odds of a flare [OR 2.27 (95% CI 1.24, 4.17)] and was associated with significantly higher SLAQ scores [β 2.31 (0.86, 3.76)]. Adjusted odds of any flare and flare with medical care were significantly elevated for those with both BTQ and ACE exposures [5.91 (2.21, 15.82) and 4.69 (1.56, 14.07), respectively]. SLAQ scores were also higher for those with both exposures [β 5.22 (3.00, 7.44)]. CONCLUSION In this cohort, those with a history of trauma reported more flares and greater disease activity. Identifying mechanisms of associations between trauma and disease activity and flares, as well as interventions to mitigate the effects of trauma exposures is critical, given the high rates of trauma exposures.
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Affiliation(s)
- Patricia Katz
- Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Sarah L Patterson
- Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Kimberly DeQuattro
- Department of Medicine, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Cristina M Lanata
- National Institutes of Health, National Human Genome Research Institute, Bethesda, MD, USA
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Division of Population Health, Atlanta, GA, USA
| | - Kurt J Greenlund
- Centers for Disease Control and Prevention, Division of Population Health, Atlanta, GA, USA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Lindsey A Criswell
- National Institutes of Health, National Human Genome Research Institute, Bethesda, MD, USA
| | - Maria Dall’Era
- Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
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18
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Escoda T, Jourde-Chiche N, Granel B, Cornec D, Chiche L. Complex relationships between inflammatory manifestations/type 1 and type 2 symptoms in systemic lupus erythematosus: A narrative literature review. Lupus 2023:9612033231179773. [PMID: 37229792 DOI: 10.1177/09612033231179773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Recent studies have highlighted that systemic lupus erythematosus (SLE) is characterized by different types of symptoms: type 1 symptoms related to inflammation and disease activity and type 2 symptoms such as fatigue, anxiety-depression, and pain. Our aim was to investigate the relation between type 1 and type 2 symptoms, and their impact on health-related quality of life (HRQoL) in SLE. METHODS A literature review was conducted about disease activity/type1 and type 2 symptoms. Articles in English published after 2000 were located on Medline via Pubmed. The articles chosen evaluated at least one type 2 symptom or HRQoL using a validated scale in adult patients. RESULTS Overall, 182 articles were analyzed and 115 were retained including 21 randomized, controlled trials and corresponding to 36 831 patients. We found that in SLE, inflammatory activity/type 1 symptoms were mostly uncorrelated with type 2 symptoms and/or HRQoL. Several studies even showing an inverse relationship. No or weak correlation was observed in 85, 3% (92, 6%), 76, 7% (74, 4%) and 37, 5% (73, 1%) of studies (patients) for fatigue, anxiety-depression, and pain, respectively. For HRQoL, no or weak correlation was observed in 77, 5% of studies (88% of patients). CONCLUSION Type 2 symptoms are poorly correlated with inflammatory activity/type 1 symptoms in SLE. Possible explanations and implications for clinical care and therapeutic evaluation are discussed.
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Affiliation(s)
- Thomas Escoda
- Service de Médecine Interne, Hôpital Européen, Marseille, France
| | - Noémie Jourde-Chiche
- Service de Néphrologie, Hôpital de la Conception, Marseille Public University Hospital System, Marseille, France
| | - Brigitte Granel
- Service de Médecine Interne, Hôpital Nord, Aix Marseille Université, Marseille Public University Hospital System, Marseille, France
| | - Divi Cornec
- Service de Rhumatologie, Hôpital de la Cavale Blanche, Brest University, Brest, France
| | - Laurent Chiche
- Service de Médecine Interne, Hôpital Européen, Marseille, France
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19
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Adaptation and validation of the Bulgarian version of the Systemic Lupus Erythematosus Quality of Life Questionnaire (L-QoL). Clin Rheumatol 2023:10.1007/s10067-023-06523-w. [PMID: 36913029 DOI: 10.1007/s10067-023-06523-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is a heterogeneous disease with multiple clinical manifestations, which causes a significant deterioration in the quality of life (QoL). The Systemic Lupus Erythematosus Quality of Life Questionnaire (L-QoL) is a lupus-specific measure used to determine the burden of the disease and it applies the need-based model of QoL. Our aim was to produce the first successfully validated foreign language version of the questionnaire. METHODS The development of the Bulgarian version involved three stages: translation, field testing and psychometric evaluation. Translation was conducted by an expert linguist working with a developer of the original L-QoL, followed by interviews with monolingual lay individuals. Face and content validity of the translation were assessed by cognitive debriefing interviews with Bulgarian SLE patients. Finally, the L-QoL was validated by administering the questionnaire to a random sample of SLE patients on two occasions, 2 weeks apart to evaluate its reliability and validity. RESULTS In the validation survey, the new Bulgarian version demonstrated high internal consistency (the Cronbach's alpha coefficient was 0.92), and test-retest reliability (0.97). Additionally, scores on the L-QoL were correlated with those on the SF-36 sections to determine convergent validity and the strongest correlation was observed between L-QoL scores and the social functioning section of the SF-36. Known group validity was established by testing the ability of the Bulgarian L-QoL to distinguish between subgroups of patients from the study pool. CONCLUSIONS The demonstrated excellent psychometric properties ensure that the Bulgarian L-QoL accurately captures the impact of SLE on the quality of life. Key points • The Bulgarian version of the L-QoL is a valid and reliable measure of QoL in lupus patients. • The Bulgarian version of the L-QoL can be used as an outcome measure in research, clinical trials and routine clinical practice.
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20
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Kamen DL, Birt JA, Hadi MA, Gibbons E, Bushnell DM, Yu R, Delbecque LA, Griffing K, Askanase A. Patient-reported disease impact of systemic lupus erythematosus with active joint symptoms: Results from the systemic lupus erythematosus-update survey. Lupus 2023; 32:342-351. [PMID: 36541633 DOI: 10.1177/09612033221147479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Many people with systemic lupus erythematosus (SLE) experience joint pain, swelling, and stiffness. These joint symptoms are associated with problems in physical functioning and work disability. We used survey data from adults with SLE to explore the burden and impact of joint symptoms. METHODS SLE-UPDATE was a 2019 cross-sectional US survey of adults with SLE. We compared respondents with "currently active" joint symptoms' and those "without currently active" joint symptoms. The active joint cohort comprised survey respondents who self-reported current "stiffness in joints" or "pain/swelling in joints" and who had moderate to severe joint pain (Worst Joint Pain Numeric Rating Scale [NRS] score ≥ 4). Respondents not fulfilling these criteria were included in the non-active joint cohort. Outcomes included frequency and severity of pain, patient-reported outcomes (LupusPRO™ and Work Productivity and Activity Impairment: Lupus [WPAI-Lupus]), satisfaction with current treatments, and importance of different treatment goals. RESULTS More respondents in the active joint cohort (N = 285) than in the non-active joint cohort (N = 215) reported pain most or all the time over the preceding 7 days (77.5% vs. 32.1%, p < .0001), fibromyalgia (45% vs. 12%, p < .0001), and higher (worse) mean scores on the Worst Pain NRS (6.5 vs. 4.8, p < .0001) and Worst Joint Pain NRS (6.7 vs. 4.5, p < .0001). Mean Lupus PRO health-related quality of life (HRQoL) total score was lower (worse) in the active joint cohort (48.9 vs. 64.1, p < .0001). WPAI-Lupus scores indicated greater work productivity losses and activity impairment in the active joint cohort. More respondents in the active joint cohort than in the non-active joint cohort were neutral or not satisfied with current treatments and rated reducing pain as a "very important" treatment goal (26.7% vs. 18.1%). CONCLUSIONS Respondents with SLE and active joint manifestations in addition to having more pain report lower HRQoL and were less satisfied with their current treatments. Comorbid fibromyalgia may play a role in joint symptoms in patient with SLE joint manifestations. There is an unmet need for new therapeutic options to reduce joint symptom burden among patients with SLE.
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Affiliation(s)
- Diane L Kamen
- Department of Medicine, 2629Medical University of South Carolina, Charleston, SC, USA
| | - Julie A Birt
- Value, Evidence, and Outcomes, 1539Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Monica A Hadi
- Patient Centred Research, 387388Evidera Inc, London, UK
| | | | | | - Ren Yu
- Patient Centred Research, 387388Evidera Inc, London, UK
| | - Laure A Delbecque
- Value, Evidence, and Outcomes, 1539Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Kirstin Griffing
- Value, Evidence, and Outcomes, 1539Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Anca Askanase
- Department of Rheumatology, 116366Columbia University College of Physicians and Surgeons, New York, NY, USA
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21
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Arcani R, Jouve E, Chiche L, Jourde-Chiche N. Categorization of patients with systemic lupus erythematosus using disease activity, patient-reported outcomes, and transcriptomic signatures. Clin Rheumatol 2023; 42:1555-1563. [PMID: 36759402 DOI: 10.1007/s10067-023-06525-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) display symptoms that are not always related to disease activity and may distort clinical trial results. Recently, a clinical categorization based on the presence of type 1 (inflammatory manifestations) and/or type 2 (widespread pain, fatigue, depression) symptoms has been proposed in SLE. Our aim was to develop a type 2 score derived from the Short-Form health survey (SF-36) to categorize SLE patients and to compare immunological and transcriptomic profiles between groups. METHOD Seventeen items from the SF-36 were selected to build a type 2 score for 50 SLE patients (100 visits; LUPUCE cohort), and the SLEDAI was used to define type 1 symptoms. Patients were categorized into four groups: minimal (no symptoms), type 1, type 2, and mixed (both type 1 and type 2 symptoms). Clinical, immunological, and transcriptomic profiles were compared between the groups. RESULTS Type 2 scores ranged from 0 to 31, with a cutoff value of 14 (75th percentile). The sample categorization was minimal in 39%, type 1 in 37%, and type 2 in 9%, and mixed in 15%. Type 2 patients were older than minimal patients and had a longer disease duration than type 1 and mixed patients. Immunological data and modular interferon signatures did not differ between the groups. CONCLUSION Patients with SLE can be categorized into four clinical groups using the SLEDAI score and our SF-36-derived type 2 score. This categorization is non-redundant with immunological or transcriptomic profiles and could prove useful to stratify patients in clinical trials. Key Points • A score derived from selected items of the SF-36 can be used to identify SLE patients with type 2 symptoms according to the Duke University categorization. • Using the SLEDAI and this type 2 score, SLE patients can be categorized into four clinical groups. • This categorization is not related to immunological activity or blood transcriptome profiles (and not to the interferon signature in particular). • This categorization could be useful in the daily care of patients as well as in clinical trials, for upstream patient stratification or for the interpretation of results.
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Affiliation(s)
- Robin Arcani
- Médecine Interne Et Thérapeutique, Hôpital de La Timone, AP-HM, Marseille, France.,C2VN, INRAe, INSERM, Aix Marseille Univ, Marseille, France
| | - Elisabeth Jouve
- Service Evaluation Médicale, Hôpital de La Conception, AP-HM, Marseille, France
| | | | - Noémie Jourde-Chiche
- C2VN, INRAe, INSERM, Aix Marseille Univ, Marseille, France. .,Centre de Néphrologie Et Transplantation Rénale, Hôpital de La Conception, AP-HM, 147 Boulevard Baille, 13005, Marseille, France.
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22
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Patterson S, Trupin L, Hartogensis W, DeQuattro K, Lanata C, Gordon C, Barbour KE, Greenlund KJ, Dall'Era M, Yazdany J, Katz P. Perceived Stress and Prediction of Worse Disease Activity and Symptoms in a Multiracial, Multiethnic Systemic Lupus Erythematosus Cohort. Arthritis Care Res (Hoboken) 2022. [PMID: 36537191 PMCID: PMC10279800 DOI: 10.1002/acr.25076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/02/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Studies have suggested a potential link between traumatic experiences, psychological stress, and autoimmunity, but the impact of stress on disease activity and symptom severity in systemic lupus erythematosus (SLE) remains unclear. The present study was undertaken to examine whether increases in perceived stress independently associate with worse SLE disease outcomes over 3 years of follow-up. METHODS Participants were drawn from the California Lupus Epidemiology Study (CLUES). Stress was measured annually using the 4-item Perceived Stress Scale (PSS). Participants with increases of ≥0.5 SD in PSS score were defined as having an increase in stress. Four outcomes were measured at the year 3 follow-up visit: physician-assessed disease activity (Systemic Lupus Erythematosus Disease Activity Index); patient-reported disease activity (Systemic Lupus Activity Questionnaire); pain (Patient-Reported Outcomes Measurement Information System [PROMIS] pain interference scale); and fatigue (PROMIS fatigue scale). Multivariable linear regression evaluated longitudinal associations of increase in stress with all 4 outcomes while controlling for potential confounders. RESULTS The sample (n = 260) was 91% female, 36% Asian, 30% White, 22% Hispanic, and 11% African American; the mean ± SD age was 46 ± 14 years. In adjusted longitudinal analyses, increase in stress was independently associated with greater physician-assessed disease activity (P = 0.015), greater self-reported disease activity (P < 0.001), more pain (P = 0.019), and more fatigue (P < 0.001). CONCLUSION In a racially diverse sample of individuals with SLE, those who experienced an increase in stress had significantly worse disease activity and greater symptom burden at follow-up compared to those with stress levels that remained stable or declined. Findings underscore the need for interventions to bolster stress resilience and support effective coping strategies among individuals living with lupus.
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Affiliation(s)
| | | | | | | | | | - Caroline Gordon
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, Georgia
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23
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Escoda T, Jourde-Chiche N, Stavris C, Retornaz F, Genot S, Daumas A, Benyamine A, Granel B, Cornec D, Chiche L. Analyse des relations complexes entre les manifestations inflammatoires et les symptômes de type 2 au cours du lupus érythémateux systémique : une revue narrative de la littérature. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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24
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Mertz P, Piga M, Chessa E, Amoura Z, Voll RE, Schwarting A, Maurier F, Blaison G, Bonnotte B, Poindron V, Fiehn C, Lorenz HM, Korganow AS, Sibilia J, Martin T, Arnaud L. Fatigue is independently associated with disease activity assessed using the Physician Global Assessment but not the SLEDAI in patients with systemic lupus erythematosus. RMD Open 2022; 8:rmdopen-2022-002395. [PMID: 36123013 PMCID: PMC9486369 DOI: 10.1136/rmdopen-2022-002395] [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: 04/06/2022] [Accepted: 07/27/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To analyse whether reported fatigue, one of the most challenging manifestations of systemic lupus erythematosus (SLE), may bias the assessment of disease activity in SLE according to the Physician Global Assessment (PGA). METHODS Patients from the Lupus BioBank of the upper Rhein database, a cross-sectional multicentre collection of detailed clinical and biological data from patients with SLE, were included. Patients had to fulfil the 1997 American College of Rheumatology criteria for SLE and the PGA (0-3 scale) at the time of inclusion had to be available. Fatigue was assessed according to the Fatigue Scale for Motor and Cognitive Functions. Univariate and multivariate regression models were built to determine which variables were associated with the PGA. RESULTS A total of 350 patients (89% female; median age: 42 years, IQR: 34-52) were included. The median Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score was 4 (IQR: 2-6). Of these 350 patients, 257 (73%) reported significant fatigue. The PGA (p=0.004) but not the SELENA-SLEDAI (p=0.43) was significantly associated with fatigue. Both fatigue and SELENA-SLEDAI were independently associated with the PGA in two different multivariate models. CONCLUSION Fatigue is independently associated with disease activity assessed using the PGA but not the SLEDAI. These findings highlight the fact that the PGA should capture only objectively active disease manifestations in order to improve its reliability.
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Affiliation(s)
- Philippe Mertz
- Service de rhumatologie, INSERM UMR-S1109, Hôpital de Hautepierre, 1 Avenue Molière BP 83049, 67098 Strasbourg Cedex, France,Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA
| | - Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, 09042 Cagliari, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, AOU University Clinic and University of Cagliari, 09042 Cagliari, Italy
| | - Zahir Amoura
- Service de Médecine Interne 2, Institut E3M, Centre national de Référence Lupus et SAPL, Assistance Publique–Hôpitaux de Paris (APHP), Groupement Hospitalier Pitié–Salpêtrière, Paris, France
| | - Reinhard E Voll
- Department of Rheumatology and Clinical Immunology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Schwarting
- Division of Rheumatology and Clinical Immunology, I.st Department of Internal Medicine Universitätsmedizin Mainz Langenbeckstr, 1 55131 Mainz, Germany
| | - Francois Maurier
- Internal Medicine Unit, Hôpitaux Privés de Metz Site Belle Isle 2 rue Belle Isle, 57045 Metz, France
| | - Gilles Blaison
- Service de médecine interne - Centre de compétence en maladies auto-immunes et systémiques rares, Hôpitaux Civils de Colmar, 39 avenue de la Liberté 68000 Colmar, France
| | - Bernard Bonnotte
- Service de médecine interne et immunologie clinique, CHU Dijon Bourgogne, 2, boulevard Mal-de-Lattre-de-Tassigny, 21000 Dijon, France
| | - Vincent Poindron
- Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA,Service d’immunologie clinique Nouvel hôpital civil, 1 place de l’hôpital, 67091 Strasbourg Cedex, France
| | - Christoph Fiehn
- ACURA Centre for Rheumatic Diseases, Rotenbachtalstr, 5 Baden-Baden, DE 76530, Germany
| | - Hanns-Martin Lorenz
- Division of Rheumatology. Dept. of Medicine V University Hospital Heidelberg, Center for Rheumatic Diseases Baden-Baden, INF 410 69120 Heidelberg, Germany
| | - Anne-Sophie Korganow
- Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA,Service d’immunologie clinique Nouvel hôpital civil, 1 place de l’hôpital, 67091 Strasbourg Cedex, France
| | - Jean Sibilia
- Service de rhumatologie, INSERM UMR-S1109, Hôpital de Hautepierre, 1 Avenue Molière BP 83049, 67098 Strasbourg Cedex, France,Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA
| | - Thierry Martin
- Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA,Service d’immunologie clinique Nouvel hôpital civil, 1 place de l’hôpital, 67091 Strasbourg Cedex, France
| | - Laurent Arnaud
- Service de rhumatologie, INSERM UMR-S1109, Hôpital de Hautepierre, 1 Avenue Molière BP 83049, 67098 Strasbourg Cedex, France,Centre National de Référence des Maladies Auto-immunes Systémiques Rares Est Sud-Ouest (RESO)-LUPUS, European Reference Networks (ERN) ReCONNET and RITA
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25
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McCoy SS, Woodham M, Bartels CM, Saldanha IJ, Bunya VY, Maerz N, Akpek EK, Makara MA, Baer AN. Symptom-Based Cluster Analysis Categorizes Sjögren's Disease Subtypes: An International Cohort Study Highlighting Disease Severity and Treatment Discordance. Arthritis Rheumatol 2022; 74:1569-1579. [PMID: 35594474 PMCID: PMC9427679 DOI: 10.1002/art.42238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Although symptom relief is a critical aspect for successful drug development in Sjögren's disease, patient experiences with Sjögren's-related symptoms are understudied. Our objective was to determine how pain, dryness, and fatigue, the cardinal symptoms of Sjögren's disease, drive cluster phenotypes. METHODS We used data from the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry and a Sjögren's Foundation survey. We performed hierarchical clustering of symptoms by levels of dryness, fatigue, and pain. Using international and US cohorts, we performed multiple logistic regression analysis to compare the clusters, which included comparisons of differences in symptoms, quality of life (QoL), medication use, and systemic manifestations. RESULTS Four similar clusters were identified among 1,454 SICCA registrants and 2,920 Sjögren's Foundation survey participants: 1) low symptom burden in all categories (LSB); 2) dry with low pain and low fatigue (DLP); 3) dry with high pain and low to moderate fatigue (DHP); and 4) high symptom burden in all categories (HSB). Distribution of SICCA registrants matching the symptom profile for each cluster was 10% in the LSB cluster, 30% in the DLP cluster, 23% in the DHP cluster, and 37% in the HSB cluster. Distribution of survey participants matching the symptom profile for each cluster was 23% in the LSB cluster, 14% in the DLP cluster, 21% in the DHP cluster, and 42% in the HSB cluster. Individuals in the HSB cluster had more total symptoms and lower QoL but lower disease severity than those in the other clusters. Despite having milder disease as measured by laboratory tests and organ involvement, individuals in the HSB cluster received immunomodulatory treatment most often. CONCLUSION We identified 4 symptom-based Sjögren's clusters and showed that symptom burden and immunomodulatory medication use do not correlate with Sjögren's end-organ or laboratory abnormalities. Findings highlight a discordance between objective measures and treatments and offer updates to proposed symptom-based clustering approaches.
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Eudy AM, Rogers JL, Corneli A, McKenna K, Maheswaranathan M, Pisetsky DS, Criscione-Schreiber LG, Doss J, Sadun RE, Sun K, Clowse MEB. Intermittent and Persistent Type 2 lupus: patient perspectives on two distinct patterns of Type 2 SLE symptoms. Lupus Sci Med 2022; 9:9/1/e000705. [PMID: 36927502 PMCID: PMC9362789 DOI: 10.1136/lupus-2022-000705] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We have developed a new conceptual model to characterise the signs and symptoms of SLE: the Type 1 and 2 SLE Model. Within the original model, Type 1 SLE consists of inflammatory manifestations like arthritis, nephritis and rashes; Type 2 SLE includes symptoms of fatigue, myalgia, mood disturbance and cognitive dysfunction. Through in-depth interviews, we explored how the Type 1 and 2 SLE Model fits within the lived experience of patients with SLE, with a focus on the connection between Type 1 and Type 2 SLE symptoms. METHODS Semistructured in-depth interviews were conducted among adult participants meeting 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria for SLE. Participants were purposefully selected for age, race, sex and nephritis history. All interviews were audio-recorded and transcribed. Data were analysed through episode profile and thematic analysis. RESULTS Through interviews with 42 patients with SLE, two patterns of Type 2 SLE emerged: Intermittent (n=18) and Persistent (n=24). Participants with Intermittent Type 2 SLE described feeling generally well when Type 1 is inactive; these participants were younger and had more internal SLE manifestations. Participants with Persistent Type 2 described always experiencing Type 2 symptoms despite inactive Type 1, although the severity may fluctuate. Participants with Persistent Type 2 SLE experienced traditional lupus symptoms of joint pain, hair loss and rash, but less often had severe organ system involvement. CONCLUSIONS By listening to the stories of our patients, we found two underlying patterns of Type 2 SLE: Intermittent Type 2 symptoms that resolve in synchrony with Type 1 inflammatory symptoms, and Persistent Type 2 symptoms that continue despite remission of Type 1 symptoms.
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Affiliation(s)
- Amanda M Eudy
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Pisetsky
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | | | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca E Sadun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Munroe ME, Young KA, Guthridge JM, Kamen DL, Gilkeson GS, Weisman MH, Ishimori ML, Wallace DJ, Karp DR, Harley JB, Norris JM, James JA. Pre-Clinical Autoimmunity in Lupus Relatives: Self-Reported Questionnaires and Immune Dysregulation Distinguish Relatives Who Develop Incomplete or Classified Lupus From Clinically Unaffected Relatives and Unaffected, Unrelated Individuals. Front Immunol 2022; 13:866181. [PMID: 35720322 PMCID: PMC9203691 DOI: 10.3389/fimmu.2022.866181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is propelled by pathogenic autoantibody (AutoAb) and immune pathway dysregulation. Identifying populations at risk of reaching classified SLE is essential to curtail inflammatory damage. Lupus blood relatives (Rel) have an increased risk of developing SLE. We tested factors to identify Rel at risk of developing incomplete lupus (ILE) or classified SLE vs. clinically unaffected Rel and healthy controls (HC), drawing from two unique, well characterized lupus cohorts, the lupus autoimmunity in relatives (LAUREL) follow-up cohort, consisting of Rel meeting <4 ACR criteria at baseline, and the Lupus Family Registry and Repository (LFRR), made up of SLE patients, lupus Rel, and HC. Medical record review determined ACR SLE classification criteria; study participants completed the SLE portion of the connective tissue disease questionnaire (SLE-CSQ), type 2 symptom questions, and provided samples for assessment of serum SLE-associated AutoAb specificities and 52 plasma immune mediators. Elevated SLE-CSQ scores were associated with type 2 symptoms, ACR scores, and serology in both cohorts. Fatigue at BL was associated with transition to classified SLE in the LAUREL cohort (p≤0.01). Increased levels of BLyS and decreased levels of IL-10 were associated with type 2 symptoms (p<0.05). SLE-CSQ scores, ACR scores, and accumulated AutoAb specificities correlated with levels of multiple inflammatory immune mediators (p<0.05), including BLyS, IL-2Rα, stem cell factor (SCF), soluble TNF receptors, and Th-1 type mediators and chemokines. Transition to SLE was associated with increased levels of SCF (p<0.05). ILE Rel also had increased levels of TNF-α and IFN-γ, offset by increased levels of regulatory IL-10 and TGF-β (p<0.05). Clinically unaffected Rel (vs. HC) had higher SLE-CSQ scores (p<0.001), increased serology (p<0.05), and increased inflammatory mediator levels, offset by increased IL-10 and TGF-β (p<0.01). These findings suggest that Rel at highest risk of transitioning to classified SLE have increased inflammation coupled with decreased regulatory mediators. In contrast, clinically unaffected Rel and Rel with ILE demonstrate increased inflammation offset with increased immune regulation, intimating a window of opportunity for early intervention and enrollment in prevention trials.
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Affiliation(s)
- Melissa E. Munroe
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- *Correspondence: Melissa E. Munroe,
| | - Kendra A. Young
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States
| | - Joel M. Guthridge
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Medicine, Oklahoma University Health Sciences Center, Oklahoma City, OK, United States
| | - Diane L. Kamen
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC, United States
| | - Gary S. Gilkeson
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC, United States
| | - Michael H. Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Mariko L. Ishimori
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Daniel J. Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David R. Karp
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - John B. Harley
- US Department of Veterans Affairs Medical Center, Cincinnati, OH, United States
| | - Jill M. Norris
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States
| | - Judith A. James
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
- Department of Medicine, Oklahoma University Health Sciences Center, Oklahoma City, OK, United States
- Department of Pathology, Oklahoma University Health Sciences Center, Oklahoma City, OK, United States
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Piga M, Chessa E, Morand EF, Ugarte-Gil MF, Tektonidou M, van Vollenhoven R, Petri M, Arnaud L. Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus: the PISCOS study. THE LANCET. RHEUMATOLOGY 2022; 4:e441-e449. [PMID: 38293958 DOI: 10.1016/s2665-9913(22)00107-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 12/13/2022]
Abstract
The Physician Global Assessment International Standardisation COnsensus in Systemic Lupus Erythematosus (PISCOS) study aimed to obtain an evidence-based and expert-based consensus standardisation of the Physician Global Assessment (PGA) scoring of disease activity in systemic lupus erythematosus (SLE). An international panel of 79 SLE experts participated in a three-round Delphi consensus process, in which 41 statements related to the PGA in SLE were rated, using a 0 (strongly disagree) to 10 (strongly agree) numerical rating scale. Statements with agreement of 75% or greater were selected and further validated by the expert panel. Consensus was reached on 27 statements, grouped in 14 recommendations, for the use of the PGA in SLE, design of the PGA scale, practical considerations for PGA scoring, and the relationship between PGA values and levels of disease activity. Among these recommendations, the expert panel agreed that the PGA should consist of a 0-3 visual analogue scale for measuring disease activity in patients with SLE in the preceding month. The PGA is intended to rate the overall disease activity, taking into account the severity of active manifestations and clinical laboratory results, but excluding organ damage, serology, and subjective findings unrelated to disease activity. The PGA scale ranges from "no disease activity" (0) to the "most severe disease activity" (3) and incorporates the values 1 and 2 as inner markers to categorise disease activity as mild (≥0·5 to 1), moderate (>1 and ≤2) and severe (>2 to 3). Only experienced physicians can rate the PGA, and it should be preferably scored by the same rater at each visit. The PISCOS results will allow for increased homogeneity and reliability of PGA ratings in routine clinical practice, definitions of remission and low disease activity, and future SLE trials.
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Affiliation(s)
- Matteo Piga
- Rheumatology Unit, AOU University Clinic and University of Cagliari, Cagliari, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, AOU University Clinic and University of Cagliari, Cagliari, Italy
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, VIC, Australia
| | - Manuel F Ugarte-Gil
- School of Medicine, Universidad Científica del Sur and Rheumatology Department, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Peru
| | - Maria Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ronald van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, Netherlands
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; Centre National de Référence des Maladies Systémiques et Autoimmunes Rares Est Sud-Ouest (RESO), Strasbourg, France.
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Eudy AM, Reeve BB, Coles T, Lin L, Rogers JL, Pisetsky DS, Criscione-Schreiber LG, Doss J, Sadun R, Sun K, Clowse MEB. The use of patient-reported outcome measures to classify type 1 and 2 systemic lupus erythematosus activity. Lupus 2022; 31:697-705. [PMID: 35343853 PMCID: PMC9348758 DOI: 10.1177/09612033221090885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We developed a model that categorizes systemic lupus erythematosus (SLE) activity into two dimensions: Type 1 SLE consists of inflammatory activity, including arthritis, nephritis, and rashes; Type 2 SLE includes fatigue, myalgia, mood disturbance, and cognitive dysfunction. Patient-reported outcome (PRO) measures have received attention as a way to capture symptomatology of SLE. The objective of this study was to explore the use of existing PRO measures to classify Type 1 and 2 SLE activity. METHODS Systemic lupus erythematosus patients completed three questionnaires: Systemic Lupus Activity Questionnaire (SLAQ), Polysymptomatic Distress Scale (PSD), and Patient Health Questionnaire (PHQ-2). SLE Disease Activity Index (SLEDAI) and physician global assessments (PGA; 0-3) for Type 1 and Type 2 activity were also recorded. High Type 1 SLE activity was defined as cSLEDAI ≥4 (scored without labs), SLEDAI ≥6, active nephritis, or Type 1 PGA ≥1.0. High Type 2 SLE activity was defined as Type 2 PGA ≥1.0. Patients with both high Type 1 and 2 activity were defined as Mixed SLE, and patients with low Type 1 and 2 activity were defined as Minimal SLE. Data were reduced with a factor analysis. Using a reduced set of 13 variables, multinomial logistic regression models estimated the probability of Minimal, Type 1, Type 2, and Mixed SLE classification. RESULTS The study included 208 patients with SLE. The model accurately predicted the clinician-based Type 1 and 2 SLE classification in 63% of patients; 73% of patients had their Type 1 SLE activity accurately predicted; and 83% had their Type 2 SLE activity accurately predicted. Performance varied by group: 87% of Minimal patients were correctly predicted to be in the Minimal SLE group, yet only about one-third of patients in the Type 1 group were correctly predicted to be in the Type 1 group. CONCLUSIONS Our findings indicate Type 2 SLE activity can be identified by patient-reported data. The use of PROs was not as accurate at predicting Type 1 activity. These findings highlight the challenges of using PROs to categorize and classify SLE symptoms since some manifestations of Type 1 activity (e.g., nephritis) may be essentially clinically silent while other Type 1 manifestations may cause severe symptoms.
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Affiliation(s)
- Amanda M. Eudy
- Department of Medicine, Duke University School of Medicine
| | - Bryce B. Reeve
- Department of Population Health Sciences, Duke University School of Medicine
| | - Theresa Coles
- Department of Population Health Sciences, Duke University School of Medicine
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine
| | | | - David S. Pisetsky
- Department of Medicine, Duke University School of Medicine,Medical Research Service Durham VAMC
| | | | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine
| | - Rebecca Sadun
- Department of Medicine, Duke University School of Medicine
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine
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Lew D, Huang X, Kellahan SR, Xian H, Eisen S, Kim AHJ. Anxiety Symptoms Among Patients With Systemic Lupus Erythematosus Persist Over Time and Are Independent of
SLE
Disease Activity. ACR Open Rheumatol 2022; 4:432-440. [PMID: 35191213 PMCID: PMC9096521 DOI: 10.1002/acr2.11417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 12/27/2022] Open
Abstract
Objective The objectives of this study are to identify patterns of anxiety symptomology over time among patients with systemic lupus erythematosus (SLE) and to assess the longitudinal relationship between SLE disease activity and anxiety symptomology. Methods Longitudinal data from 139 patients with American College of Rheumatology or Systemic Lupus International Collborating Clinic (SLICC)‐classified SLE were analyzed. Anxiety symptomology was assessed using the Patient‐Reported Outcomes Measurement Information System (PROMIS) Emotional Distress: Anxiety Short Form 8a. SLE disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)‐2000 (S2K) and S2K Responder Index 50 (S2K RI‐50). Group‐based trajectory modeling (GBTM) identified longitudinal trajectories of anxiety symptomology. The relationship between disease activity and anxiety over time was assessed using multilevel linear regressions. Results The mean patient age was 40.2 years (standard deviation [SD], 12.7); 90.6% were female, and 56.1% were of Black race. All patients had at least three PROMIS anxiety scores over an average of 30.9 months (SD, 13.0). GBTM identified four trajectories of anxiety symptomology, labeled as the following: low (LA), average (AA), moderate (MA), and high anxiety (HA). Black patients were 2.47 (95% confidence interval: 1.19‐5.12) times as likely as White patients to be classified into the MA or HA groups compared with the LA or AA groups. On multivariable analysis, active SLE disease was not significantly associated with anxiety over time (P = 0.19). Conclusion Anxiety trajectories remained stable over time, and racial differences in anxiety severity were observed. SLE disease activity was not longitudinally associated with anxiety after controlling for depression and other factors. Further understanding of the factors that contribute to the persistence of anxiety among individuals with SLE is necessary.
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Affiliation(s)
- Daphne Lew
- Washington University in St. Louis School of Medicine St. Louis Missouri
| | - Xinliang Huang
- Washington University in St. Louis School of Medicine St. Louis Missouri
| | - Sarah R. Kellahan
- Washington University in St. Louis School of Medicine St. Louis Missouri
| | - Hong Xian
- Saint Louis University St. Louis Missouri
| | - Seth Eisen
- Washington University in St. Louis School of Medicine St. Louis Missouri
| | - Alfred H. J. Kim
- Washington University in St. Louis School of Medicine St. Louis Missouri
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31
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Escoda T, Jourde-Chiche N, Cornec D, Chiche L. [Toward a better clinical stratification of patients with autoimmune diseases to improve research and care within its biopsychosocial dimensions]. Rev Med Interne 2022; 43:71-74. [PMID: 35000766 DOI: 10.1016/j.revmed.2021.10.337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/28/2021] [Indexed: 01/24/2023]
Affiliation(s)
- T Escoda
- Service de médecine interne, hôpital Européen, Marseille, France
| | - N Jourde-Chiche
- Service de néphrologie, hôpital de la Conception, Marseille, France
| | - D Cornec
- Service de rhumatologie, hôpital de la Cavale Blanche, Brest, France
| | - L Chiche
- Service de médecine interne, hôpital Européen, Marseille, France.
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Molina E, Petri M, Manno R, Williamson L, Williamson L, Timlin H. A prescription for exercise in systemic lupus erythematosus. Lupus 2021; 30:2183-2190. [PMID: 34903093 DOI: 10.1177/09612033211061060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with systemic lupus erythematosus (SLE) have increased cardiovascular risk, and fatigue is a major subjective complaint. Sedentary lifestyle has been shown to have negative health impacts in cardiovascular and rheumatic disease, though exercise has not traditionally been incorporated into routine therapy recommendations. Regular exercise in SLE may improve difficult to treat Type 2 symptoms, such as fatigue, depression, stress, and quality of life. Insufficient counseling on exercise by physicians is a notable barrier for SLE patients to engage in physical activity. Aerobic exercise regimens are more commonly studied, and have been shown to improve cardiovascular health in SLE. Exercise may improve some inflammatory markers, though does not definitively affect SLE clinical disease activity. Physical activity should be recommended to improve quality of life and cardiovascular health in patients with SLE. Developing clearer guidelines for exercise regimens in a patient-centered manner is warranted, especially given diverse phenotypes of SLE patients and varying degrees of physical limitations.
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Affiliation(s)
- Emily Molina
- Department of Internal Medicine, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Petri
- Department of Internal Medicine, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca Manno
- Department of Rheumatology, 249252Comprehensive Orthopaedic Global, Saint Thomas, VI, USA
| | - Luke Williamson
- Department of Rheumatology, 8539Westmead Hospital, Westmead, NSW, USA
| | - Lyn Williamson
- Department of Rheumatology, 8539Great Western Hospital Wiltshire, Swindon, UK
| | - Homa Timlin
- Division of Rheumatology, 1501Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lockshin MD, Crow MK, Barbhaiya M. When a Diagnosis Has No Name: Uncertainty and Opportunity. ACR Open Rheumatol 2021; 4:197-201. [PMID: 34806330 PMCID: PMC8916551 DOI: 10.1002/acr2.11368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Diagnostic uncertainty, commonly encountered in rheumatology and other fields of medicine, is an opportunity: Stakeholders who understand uncertainty's causes and quantitate its effects can reduce uncertainty and can use uncertainty to improve medical practice, science, and administration. To articulate, bring attention to, and offer recommendations for diagnostic uncertainty, the Barbara Volcker Center at the Hospital for Special Surgery sponsored, in April 2021, a virtual international workshop, “When a Diagnosis Has No Name.” This paper summarizes the opinions of 72 stakeholders from the fields of medical research, industry, federal regulatory agencies, insurers, hospital management, medical philosophy, public media, health care law, clinical rheumatology, other specialty areas of medicine, and patients. Speakers addressed the effects of diagnostic uncertainty in their fields. The workshop addressed the following six questions: What is a diagnosis? What are the purposes of diagnoses? How do doctors assign diagnoses? What is uncertainty? What are its causes? How does understanding uncertainty offer opportunities to improve all fields of medicine? The workshop's conveners systematically reviewed video recordings of formal presentations, video recordings of open discussion periods, manuscripts, and slide files submitted by the speakers to develop consensus take‐home messages, which were as follows: Diagnostic uncertainty causes harm when patients lack access to laboratory test and treatments, do not participate in research studies, are not counted in administrative and public health documents, and suffer humiliation in their interactions with others. Uncertainty offers opportunities, such as quantifying uncertainty, using statistical technologies and automated intelligence to stratify patient groups by level of uncertainty, using a common vocabulary, and considering the effects of time.
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Affiliation(s)
- Michael D Lockshin
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Mary K Crow
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Medha Barbhaiya
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
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Mindfulness-Based Stress Reduction for Systemic Lupus Erythematosus: A Mixed-Methods Pilot Randomized Controlled Trial of an Adapted Protocol. J Clin Med 2021; 10:jcm10194450. [PMID: 34640468 PMCID: PMC8509215 DOI: 10.3390/jcm10194450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The psychological effects of systemic lupus erythematosus (SLE) are tremendous. This pilot mixed-methods randomized controlled trial aimed to evaluate the effects of a mindfulness-based stress reduction (MBSR) adapted protocol on psychological distress among SLE patients. METHODS 26 SLE patients were randomly assigned to MBSR group therapy (n = 15) or a waitlist (WL) group (n = 11). An adapted MBSR protocol for SLE was employed. Three measurements were conducted: pre-intervention, post-intervention and 6-months follow up. A sub-sample (n = 12) also underwent qualitative interviews to assess their subjective experience of MBSR. RESULTS Compared to the WL, the MBSR group showed greater improvements in quality of life, psychological inflexibility in pain and SLE-related shame. Analysis among MBSR participants showed additional improvements in SLE symptoms and illness perception. Improvements in psychological inflexibility in pain and SLE-related shame remained stable over six months, and depression levels declined steadily from pre-treatment to follow-up. Qualitative analysis showed improvements in mindfulness components (e.g., less impulsivity, higher acceptance), as well as reduced stress following MBSR. CONCLUSIONS These results reveal the significant therapeutic potential of MBSR for SLE patients. With its emphasis on acceptance of negative physical and emotional states, mindfulness practice is a promising treatment option for SLE, which needs to be further applied and studied.
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Nguyen MH, Huang FF, O’Neill SG. Patient-Reported Outcomes for Quality of Life in SLE: Essential in Clinical Trials and Ready for Routine Care. J Clin Med 2021; 10:jcm10163754. [PMID: 34442047 PMCID: PMC8396817 DOI: 10.3390/jcm10163754] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Patient-reported outcome (PRO) instruments are widely used to assess quality of life in Systemic Lupus Erythematosus (SLE) research, and there is growing evidence for their use in clinical care. In this review, we evaluate the current evidence for their use in assessing quality of life in SLE in both research and clinical settings and examine the different characteristics of the commonly used PRO tools. There are now several well-validated generic and SLE-specific tools that have demonstrated utility in clinical trials and several tools that complement activity and damage measures in the clinical setting. PRO tools may help overcome physician–patient discordance in SLE and are valuable in the assessment of fibromyalgia and type 2 symptoms such as widespread pain and fatigue. Future work will identify optimal PRO tools for different settings but, despite current limitations, they are ready to be incorporated into patient care.
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Affiliation(s)
- Matthew H. Nguyen
- Liverpool Hospital, Liverpool, NSW 2170, Australia;
- Pathology Department, School of Medical Sciences, Faculty of Medicine, University of New South Wales, Kensington, NSW 2052, Australia
| | - Frank F. Huang
- Rheumatology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia;
| | - Sean G. O’Neill
- Rheumatology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia;
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, St Leonards, NSW 2065, Australia
- Correspondence: ; Tel.: +61-02-94631890
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Leung J, Kloos L, Kim AH, Baker EA. Development of a digital toolkit to improve quality of life of patients with systemic lupus erythematosus. Digit Health 2021; 7:20552076211033423. [PMID: 34408903 PMCID: PMC8365175 DOI: 10.1177/20552076211033423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this manuscript is to detail development and initial usability
testing of an e-toolkit designed to provide skills and knowledge around
self-management behaviors for individuals living with systemic lupus
erythematosus. Methods Researchers worked with a steering committee of patients and providers to (1)
develop a clickable prototype of an e-toolkit and (2) conduct alpha
(individuals not affiliated with an academic clinic as patient or provider)
and beta (individual patients with systemic lupus erythematosus as well as
members of the clinic healthcare team and individuals who work in patient
advocacy organizations) usability testing through semistructured
interviews. Results During the review of the e-toolkit, the feedback provided by participants in
both alpha and beta groups centered on two overarching themes: (1) improving
user interface and materials and (2) integration of information and supports
between toolkit and clinical personnel. Conclusion Digital approaches that are tailored to individual symptom variation and
integrated with a clinical system have the opportunity to enhance ongoing
clinical care. These findings support movement toward integrated, team-based
care models, tailored digital resources, and use of expanded virtual
interaction options to ensure on-going engagement between healthcare
providers and systemic lupus erythematosus patients.
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Affiliation(s)
- Jerik Leung
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, USA
| | | | - Alfred Hj Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, USA
| | - Elizabeth A Baker
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, USA
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Park EH, Ha YJ, Kang EH, Song YW, Scofield RH, Lee YJ. Baseline disease activity influences subsequent achievement of patient acceptable symptom state in Sjögren's syndrome. Rheumatology (Oxford) 2021; 60:2714-2724. [PMID: 33188390 DOI: 10.1093/rheumatology/keaa687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/02/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To investigate longitudinal changes of the EULAR SS Patient-Reported Index (ESSPRI) and EULAR SS Disease Activity Index (ESSDAI), and identify factors associated with patient acceptable symptom state (PASS) in patients with primary SS (pSS). METHODS We assessed ESSPRI, ESSDAI, clinical ESSDAI (ClinESSDAI), EULAR Sicca Score, EuroQoL 5-dimension (EQ-5D), Fatigue Severity Score, Beck Depression Inventory, and patient global assessment (PGA) for pSS, and visual analogue scale (VAS) scores for glandular and extra-glandular symptoms at baseline and follow-up. The responses to the currently available standards of care were evaluated by the PASS, the minimal clinically important improvement (MCII) of ESSPRI and ESSDAI, and a modified SS Responder Index-30 (mSSRI-30) response. RESULTS Among 115 patients enrolled, 102 (88.7%) completed a median 3-year follow-up. The ESSPRI, ClinESSDAI and EQ-5D levels remained stable, although the PGA and ESSDAI significantly improved (both P <0.05). Of the 102 patients, 52 (51.0%) patients achieved the PASS at the follow-up and tended to attain the ESSPRI-MCII and mSSRI-30 (both P < 0.001) more frequently than the non-PASS group. Multivariate analysis revealed that the PASS was significantly associated with baseline ESSPRI negatively [odds ratio (OR) 0.609] and ESSDAI positively (OR 1.224). When categorized using baseline ESSPRI and ESSDAI, a subgroup of low ESSPRI and high ESSDAI reached a PASS achievement rate of 79.3%. CONCLUSION Although longitudinal changes in ESSPRI and ClinESSDAI are stable in pSS, baseline ESSPRI and ESSDAI could provide prognostic information on the subsequent achievement of PASS, using currently available treatments. A categorization model using ESSPRI and ESSDAI may have clinical implications.
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Affiliation(s)
- Eun Hye Park
- Division of Rheumatology, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea.,Division of Rheumatology, Department of Internal Medicine, Hyundae General Hospital, Namyangju, Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeong Wook Song
- WCU Department of Molecular Medicine and Biopharmaceutical Sciences, Medical Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - R Hal Scofield
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA.,Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,US Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Pisetsky DS, Eudy AM, Clowse MEB, Rogers JL. The Categorization of Pain in Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2021; 47:215-228. [PMID: 33781491 DOI: 10.1016/j.rdc.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Systemic lupus erythematous is a systemic autoimmune disease that can cause severe pain and impair quality of life. Pain in lupus can arise from a variety of mechanisms and is usually assessed in terms of activity and damage. In contrast, categorization of symptoms as type 1 and type 2 manifestations encompasses a broader array of symptoms, including widespread pain, fatigue, and depression that may track together. The categorization of symptoms as type 1 and type 2 manifestations can facilitate communication between patient and provider as well as provide a framework to address more fully the complex symptoms experienced by patients.
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Affiliation(s)
- David S Pisetsky
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA; Medical Research Service, Durham Veterans Administration Medical Center, Durham, NC, USA.
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC, USA
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Katz P, Pedro S, Trupin L, Yelin E, Michaud K. The Impact of Asthma and Chronic Obstructive Pulmonary Disease (COPD) on Patient-Reported Outcomes in Systemic Lupus Erythematosus (SLE). ACR Open Rheumatol 2021; 3:221-230. [PMID: 33609085 PMCID: PMC8063140 DOI: 10.1002/acr2.11212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background Risk of asthma and chronic obstructive pulmonary disease (COPD) may be elevated in systemic lupus erythematosus (SLE), but little research has studied the impact of these conditions on SLE outcomes. We examined prevalence, incidence, and impact of self‐reported asthma and COPD in two US‐based SLE cohorts (FORWARD and Lupus Outcomes Study [LOS]). Methods Prevalence of asthma and COPD were defined as presence of conditions at individuals’ first interviews; incidence was defined as new reports over the next 3 years. Cross‐sectional associations of asthma/COPD with patient‐reported outcomes (PROs) and longitudinal analyses associations with asthma/COPD at entry with PROs 3 years later were examined. Results In FORWARD, 19.8% and 8.3% participants reported asthma and COPD, respectively, at entry. In LOS, 36.0% reported the presence of either (US population comparisons: asthma, 9.7%; COPD, 6.1%). Cross‐sectionally, asthma/COPD was associated with worse PROs, including disease activity. In FORWARD, individuals with asthma experienced greater worsening of fatigue, pain, and global health ratings longitudinally; individuals with COPD experienced greater increases in self‐reported SLE activity. However, no such patterns were noted in the LOS. Conclusion Asthma and COPD appeared to be more common in SLE than in the general US population and were associated with worse status on PROs cross‐sectionally. Asthma was linked to decrements in PROs longitudinally.
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Affiliation(s)
- Patricia Katz
- University of California San Francisco, San Francisco, California
| | - Sofia Pedro
- FORWARD, the National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Laura Trupin
- University of California San Francisco, San Francisco, California
| | - Edward Yelin
- University of California San Francisco, San Francisco, California
| | - Kaleb Michaud
- FORWARD, the National Databank for Rheumatic Diseases, Wichita, Kansas.,University of Nebraska Medical Center, Omaha, Nebraska
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40
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Leung J, Baker EA, Kim AHJ. Exploring intentional medication non-adherence in patients with systemic lupus erythematosus: the role of physician-patient interactions. Rheumatol Adv Pract 2021; 5:rkaa078. [PMID: 33604502 PMCID: PMC7878846 DOI: 10.1093/rap/rkaa078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/03/2020] [Indexed: 01/22/2023] Open
Abstract
Objective Medication non-adherence contributes to worse health outcomes among SLE patients. The underlying mechanisms that drive medication non-adherence are poorly understood. The purpose of this study was to explore possible mechanisms of medication non-adherence by eliciting patient experiences. Methods Consented adult patients with ACR- or SLICC-classified SLE were recruited. Ten semi-structured interviews were conducted across six participants. Interviews were audio recorded, transcribed, and analysed using an iterative process. The findings were presented to an interactive public forum with SLE patients, family members and friends of patients, and health-care professionals to assess validity and for elaboration of the concepts developed. Results The following three interrelated themes emerged from the interviews. First, why do rheumatologists not know more about lupus or share what they do know with their patients? Second, why do I have to take so many drugs and why do the drugs not work? Third, if my rheumatologist cannot communicate with me, why should I follow the prescribed medication regimen? Conclusion Our exploratory findings lay out a possible underlying logic by which patients might choose intentionally to engage with medication non-adherence behaviours. Patients suggested that poor communication with their rheumatologists along with a lack of validation of their symptoms contributed to them not valuing the recommendations of physicians. This also contributed to development of a cynical outlook and little belief that medication would improve their condition. Although further work is needed to validate these findings, our preliminary work suggests that interventions focusing on the development of communication skills among both patients and rheumatologists are necessary to reduce medication non-adherence.
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Affiliation(s)
- Jerik Leung
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University
| | - Elizabeth A Baker
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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41
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Roe K. An explanation of the pathogenesis of several autoimmune diseases in immuno-compromised individuals. Scand J Immunol 2020; 93:e12994. [PMID: 33151588 DOI: 10.1111/sji.12994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022]
Abstract
Some pathogen infections and immune system deficiencies have been linked to a few autoimmune diseases. However, the pathogenesis of most autoimmune diseases is unknown. An explanatory hypothesis for the pathogenesis of infection-initiated autoimmune diseases is provided. Virulent pathogen infections create extensive pathogen antigens that frequently require antibodies. These antibodies create extensive antigen-antibody immune complexes, which some immuno-compromised individuals will not adequately eliminate. This will cause inflammatory type III hypersensitivity symptoms, including protease releases that destroy epithelium, mesothelium and endothelium basement membranes, express new immunogenic antigens from previously sequestered basement membrane constituents, and ultimately induce new autoantibodies. This can continue after the infection ends, if the first wave of protease attacks on basement membranes induces new autoantibodies that cause new uncleared antigen-antibody immune complexes and type III hypersensitivity reactions. The secreted proteases and other enzymes will have preferred substrates and these proteases or other enzymes by themselves, or by their processed protein substrates, can express immunogenic antigens that induce new autoantibodies and initiate various autoimmune diseases. In summary, several autoimmune diseases can be initiated in immuno-compromised individuals during extensive pathogen infections, if these individuals have two immune problems: (a) slow or weak initial immune responses that result in a reliance on antibodies and (b) an inability to eliminate the resulting antigen-antibody immune complexes by phagocytosis. These two immune problems and the resulting immune system type III hypersensitivity reaction can explain the causation of several autoimmune diseases, including the most common and the rarest autoimmune diseases, both their differences and their similarities.
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Rekvig OP. Autoimmunity and SLE: Factual and Semantic Evidence-Based Critical Analyses of Definitions, Etiology, and Pathogenesis. Front Immunol 2020; 11:569234. [PMID: 33123142 PMCID: PMC7573073 DOI: 10.3389/fimmu.2020.569234] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022] Open
Abstract
One cannot discuss anti-dsDNA antibodies and lupus nephritis without discussing the nature of Systemic lupus erythematosus (SLE). SLE is insistently described as a prototype autoimmune syndrome, with anti-dsDNA antibodies as a central biomarker and a pathogenic factor. The two entities, “SLE” and “The Anti-dsDNA Antibody,” have been linked in previous and contemporary studies although serious criticism to this mutual linkage have been raised: Anti-dsDNA antibodies were first described in bacterial infections and not in SLE; later in SLE, viral and parasitic infections and in malignancies. An increasing number of studies on classification criteria for SLE have been published in the aftermath of the canonical 1982 American College of Rheumatology SLE classification sets of criteria. Considering these studies, it is surprising to observe a nearby complete absence of fundamental critical/theoretical discussions aimed to explain how and why the classification criteria are linked in context of etiology, pathogenicity, or biology. This study is an attempt to prioritize critical comments on the contemporary definition and classification of SLE and of anti-dsDNA antibodies in context of lupus nephritis. Epidemiology, etiology, pathogenesis, and measures of therapy efficacy are implemented as problems in the present discussion. In order to understand whether or not disparate clinical SLE phenotypes are useful to determine its basic biological processes accounting for the syndrome is problematic. A central problem is discussed on whether the clinical role of anti-dsDNA antibodies from principal reasons can be accepted as a biomarker for SLE without clarifying what we define as an anti-dsDNA antibody, and in which biologic contexts the antibodies appear. In sum, this study is an attempt to bring to the forum critical comments on the contemporary definition and classification of SLE, lupus nephritis and anti-dsDNA antibodies. Four concise hypotheses are suggested for future science at the end of this analytical study.
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Affiliation(s)
- Ole Petter Rekvig
- Department of Medical Biology, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,Fürst Medical Laboratory, Oslo, Norway
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43
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Nyman E, Vaughan T, Desta B, Wang X, Barut V, Emmas C. Characteristics and Symptom Severity of Patients Reporting Systemic Lupus Erythematosus in the PatientsLikeMe Online Health Community: A Retrospective Observational Study. Rheumatol Ther 2020; 7:201-213. [PMID: 32008212 PMCID: PMC7021880 DOI: 10.1007/s40744-020-00195-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Online health communities and research networks such as PatientsLikeMe (PLM) capture patient perspectives of diseases, including systemic lupus erythematosus (SLE). We performed a retrospective observational study of data provided by patients in the PLM SLE community to characterize demographics, clinical characteristics, patient experience, and symptom impact. METHODS Adults who registered with PLM in 2011-2017 and reported SLE diagnosis and treatment with one or more SLE-related drug (antimalarials, immunosuppressives, corticosteroids, calcineurin inhibitors, or biologics) were included in the analysis. Information reported within 30 days from PLM registration was used to assess patient eligibility; demographics and clinical characteristics; and primary outcome measures of SLE treatments, symptoms, primary lupus manifestations, and comorbidities. RESULTS Among 21,101 PLM members included in this analysis, median ages at registration, onset of SLE symptoms, and SLE diagnosis were 46 years (interquartile range [IQR] 38-53, n = 21,101), 30 years (IQR 21-39; n = 6489), and 36 years (IQR 27-44; n = 6936), respectively. Most patients were female (96.8%, n = 20,370). Country of residence was reported by 19,502 patients (92.4%), of whom 18,491 (94.8%) were US residents. Race was recorded by 17,994 patients (85.3%), of whom 67.8% were white and 22.4% were black/African American. Patients reported a mean of 2.2 SLE-related medications, including antimalarials (83.8%), corticosteroids (78.8%), immunosuppressives (32.3%), and biologics (9.4%). Fatigue, pain, and joint pain were rated as moderate or severe by at least 80% of patients who reported these symptoms. Reported primary lupus manifestations and comorbidities included fibromyalgia (7.9%), discoid lupus (6.8%), lupus nephritis (6.3%), rheumatoid arthritis (4.8%), subacute cutaneous lupus (4.7%), central nervous system lupus (3.9%), Sjögren's syndrome (3.9%), and lupus pneumonitis (3.1%). CONCLUSIONS Age, sex, and race of patients in the PLM SLE community are broadly consistent with characteristics of the general SLE population in the United States. The PLM SLE population may provide valuable data on self-reported patient experience. Plain language summary available for this article.
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Affiliation(s)
| | - Timothy Vaughan
- Data Sciences, Cohen Veterans Bioscience, Cambridge, MA, USA
| | - Barnabas Desta
- Global Pricing and Market Access, AstraZeneca, Gaithersburg, MD, USA
| | - Xia Wang
- Data Science and AI, AstraZeneca, Gaithersburg, MD, USA
| | - Volkan Barut
- BioPharmaceuticals Medical, AstraZeneca, Luton, UK
| | - Cathy Emmas
- BioPharmaceuticals Medical, AstraZeneca, Luton, UK.
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Rogers JL, Eudy AM, Pisetsky D, Criscione-Schreiber LG, Sun K, Doss J, Clowse MEB. Using Clinical Characteristics and Patient-Reported Outcome Measures to Categorize Systemic Lupus Erythematosus Subtypes. Arthritis Care Res (Hoboken) 2020; 73:386-393. [PMID: 31909888 DOI: 10.1002/acr.24135] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 12/31/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The type 1 and type 2 systemic lupus erythematosus (SLE) categorization system was recently proposed to validate the patients' perspective of disease and to capture a more comprehensive spectrum of symptoms. The objective of this study was to characterize the clinical manifestations of SLE subtypes and to determine the correlation between the patient- and physician-reported measures used in the model. METHODS This was a cross-sectional study of patients with SLE in a university clinic. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and 2011 American College of Rheumatology fibromyalgia (FM) criteria. Active SLE was defined as Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score ≥6, clinical SLEDAI score ≥4, or active lupus nephritis. We identified 4 groups: type 1 SLE (active SLE without FM), type 2 SLE (inactive SLE with FM), mixed SLE (active SLE with FM), and minimal SLE (inactive SLE without FM). RESULTS In this cohort of 212 patients (92% female, mean age 45 years), 30% had type 1 SLE, 8% had type 2 SLE, 13% had mixed SLE, and 49% had minimal SLE. Regardless of SLE disease activity, patients with FM (21%), reported higher SLAQ scores, patient global assessment scores, and self-reported lupus flare that resulted in discordance between patient- and physician-reported measures. CONCLUSION Fatigue, widespread pain, sleep dysfunction, and mood disorders are common symptoms in SLE. Identifying these symptoms as type 2 SLE may be a method to improve patient communication and understanding. The level of type 2 SLE impacts patients' perception of disease and self-reported symptoms. The SLAQ may need to be reinterpreted based on the FM severity scale.
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Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, North Carolina
| | - David Pisetsky
- Durham Veterans Affairs Hospital and Duke University Medical Center, Durham, North Carolina
| | | | - Kai Sun
- Duke University Medical Center, Durham, North Carolina
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
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