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Zhang E, Capponi S, Scobell R, Alonzi G, Hlobik M, Daga A, Meidan E, Wobma H, Kim L, Henderson LA, Case S, Nigrovic PA, Stone JH, Costenbader KH, Son MBF, Chang JC. Real-world application of the pediatric Glucocorticoid Toxicity Index in childhood-onset lupus. Semin Arthritis Rheum 2024; 68:152516. [PMID: 39059156 PMCID: PMC11381140 DOI: 10.1016/j.semarthrit.2024.152516] [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: 04/06/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES The pediatric Glucocorticoid Toxicity Index (pGTI) is a new, pediatric-specific tool to quantify glucocorticoid (GC)-related morbidity in children. We evaluated the feasibility and construct validity of retrospective pGTI scoring in patients with pediatric-onset systemic lupus erythematosus (pSLE) and identified risk factors for cumulative toxicity. METHODS We conducted a retrospective cohort study of patients with pSLE treated with GCs at two pediatric centers (1999-2023). GC exposure was estimated using interval-averaged oral prednisone-equivalent dose and cumulative prednisone-equivalent dose. We scored change in GC toxicity every 6 months (±2) using a modified pGTI including 7 of 10 domains. We calculated the Cumulative Worsening Score (CWS), a continuous summation of toxicity accrued. Mixed effects linear regression was used to identify factors associated with CWS. RESULTS There were 126 patients with pSLE, including 88 with nephritis, with a median of 6 visits/patient. Nearly half (47 %) experienced toxicity in the Blood Pressure domain. Other common toxicities were mood disturbance (25 %), followed by increased body mass index (BMI), striae, and sleep disturbance (21 % each). Decreased growth velocity was observed in 18 %. There was modest correlation between cumulative GC dose and CWS (rho 0.3; p < 0.01). Greater cumulative toxicity was associated with younger age, elevated BMI, and rituximab use at the time of GC initiation, albeit indications for the latter were not captured. CONCLUSIONS Patients with pSLE experience a high burden of GC toxicity, particularly related to blood pressure, BMI, sleep, and growth. Standardized, pediatric-specific GC toxicity assessment is feasible in real-world settings and can facilitate evaluation of strategies to reduce morbidity in children requiring chronic GC treatment.
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Affiliation(s)
- Emily Zhang
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Capponi
- Division of Rheumatology, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rebecca Scobell
- Division of Rheumatology, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gabrielle Alonzi
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Madeline Hlobik
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ankana Daga
- Division of Nephrology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Esra Meidan
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Holly Wobma
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Liyoung Kim
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Siobhan Case
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joyce C Chang
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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2
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Sagcal-Gironella ACP, Merritt A, Mizuno T, Dharnidharka VR, McDonald J, DeGuzman M, Wahezi D, Goilav B, Onel K, Kim S, Cody E, Wu EY, Cannon L, Hayward K, Okamura DM, Patel PN, Greenbaum LA, Rouster-Stevens KA, Cooper JC, Ruth NM, Ardoin S, Cook K, Borgia RE, Hersh A, Huang B, Devarajan P, Brunner H. Efficacy and Safety of Pharmacokinetically-Driven Dosing of Mycophenolate Mofetil for the Treatment of Pediatric Proliferative Lupus Nephritis-A Double-Blind Placebo Controlled Clinical Trial (The Pediatric Lupus Nephritis Mycophenolate Mofetil Study). JOURNAL OF CLINICAL TRIALS 2024; 14:563. [PMID: 39035447 PMCID: PMC11258879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
Background The safety and efficacy of mycophenolate mofetil (MMF) for lupus nephritis (LN) treatment is established in adults and in some children. MMF is rapidly converted to the biologically active metabolite mycophenolic acid (MPA) whose pharmacokinetics (PK) is characterized by large inter- and intra-individual variability. Methods/Design This randomized, double-blind, active comparator, controlled clinical trial of pediatric subjects with proliferative LN compares pharmacokinetically-guided precision-dosing of MMF (MMFPK, i.e. the dose is adjusted to the target area under the concentration-time curve (AUC0-12h) of MPA ≥ 60-70 mg*h/L) and MMF dosed per body surface area (MMFBSA, i.e. MMF dosed 600 mg/m2 body surface area), with MMF dosage taken about 12 hours apart. At baseline, subjects are randomized 1:1 to receive blinded treatment with MMFPK or MMFBSA for up to 53 weeks. The primary outcome is partial clinical remission of LN (partial renal response, PRR) at week 26, and the major secondary outcome is complete renal response (CRR) at week 26. Subjects in the MMFBSA arm with PRR at week 26 will receive MMFPK from week 26 onwards, while subjects with CRR will continue MMFBSA or MMFPK treatment until week 53. Subjects who achieve PRR at week 26 are discontinued from study intervention. Discussion The Pediatric Lupus Nephritis Mycophenolate Mofetil (PLUMM) study will provide a thorough evaluation of the PK of MMF in pediatric LN patients, yielding a head-to-head comparison of MMFBSA and MMFPK for both safety and efficacy. This study has the potential to change current treatment recommendations for pediatric LN, thereby significantly impacting childhood-onset SLE (cSLE) disease prognosis and current clinical practice.
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Affiliation(s)
- Anna Carmela P Sagcal-Gironella
- Division of Pediatric Rheumatology, Hackensack University Medical Center, Hackensack, New Jersey, USA
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Angela Merritt
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vikas R Dharnidharka
- Department of Pediatric Nephrology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Joseph McDonald
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - Marietta DeGuzman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Dawn Wahezi
- Department of Pediatric Rheumatology, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Beatrice Goilav
- Pediatric Nephrology, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Karen Onel
- Department of Pediatric Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Susan Kim
- Department of Rheumatology, University of California, San Francisco, California, USA
| | - Ellen Cody
- Department of Pediatric Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eveline Y Wu
- Department of Pediatric Rheumatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laura Cannon
- Department of Pediatric Rheumatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kristen Hayward
- Department of Pediatric Rheumatology, University of Washington, Seattle, Washington, USA
| | - Daryl M Okamura
- Department of Pediatric Nephrology, University of Washington, Seattle, Washington, USA
| | - Pooja N Patel
- Depatrment of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Larry A Greenbaum
- Department of Pediatric Nephrology, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kelly A Rouster-Stevens
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jennifer C Cooper
- Department of Pediatric Rheumatology, University of Colorado, Denver, Colorado, USA
| | - Natasha M Ruth
- Department of Pediatric Rheumatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stacy Ardoin
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Kathryn Cook
- Division of Rheumatology, Akron Children’s, Akron, Ohio, USA
| | - R Ezequiel Borgia
- Department of Pediatric Allergy, Immunology and Rheumatology, UH Rainbow Babies & Children’s Hospital, Cleveland, Ohio, USA
| | - Aimee Hersh
- Department of Pediatrics, Immunology and Rheumatology, University of Utah, Salt Lake City, Utah, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Elshaer R, Jaber S, Odeh N, Arbili L, Al-Mayouf SM. Safety and efficacy of biologics in childhood systemic lupus erythematosus: a critical systematic review. Clin Rheumatol 2024; 43:863-877. [PMID: 38079010 DOI: 10.1007/s10067-023-06833-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/20/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
Biologic agents are increasingly being used to treat adult patients with systemic lupus erythematosus (SLE). However, the available data on biologic agents' use in childhood-onset SLE (cSLE) remains limited. To collate available evidence related to the efficacy and safety of using biologic agents in cSLE. The study followed the PRISMA checklist for reporting the data and conducted a thorough search using PubMed, Cochrane Library, and Scopus from January 2005 to August 2023. Only articles meeting specific criteria were included, focusing on cSLE, the use of biologic agents, and having outcome measures at six- and 12-month follow-ups for safety and efficacy. Case reports were excluded, and four independent reviewers screened the articles for accuracy, with a fifth reviewer resolving any discrepancies that arose to achieve a consensus. The final selection included 18 studies with a total of 593 patients treated with biologic agents for severe and/ or refractory cSLE. The most common indication for using biologic agents was lupus nephritis. Rituximab was used in 12 studies, while belimumab was used in six studies. The studies evaluated the efficacy of biologic agents based on SLE disease activity scores, laboratory parameter improvements, and reduced corticosteroid dosage. Positive outcomes were reported, with improvements in renal, hematologic, and immunologic parameters along with mild adverse effects, mostly related to mild infections and infusion reactions. Belimumab and rituximab have shown promise as potential treatments for severe and refractory cSLE cases, leading to decreased disease activity and complete or partial remission in many patients with an acceptable safety profile. However, further research is needed to better understand their benefits and potential risks in these patients. Key Points • This review emphasizes the lack of sufficient randomized controlled trials exploring the use of biologics in childhood systemic lupus erythematosus (cSLE). • Treatment plans for cSLE are being derived from those used for adult systemic lupus erythematosus. • According to current evidence, belimumab and rituximab can be potential treatment options for refractory and severe cases of cSLE. • Additional studies are required to reach more definitive conclusions.
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Affiliation(s)
- Rawan Elshaer
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Samar Jaber
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nour Odeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Lana Arbili
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sulaiman M Al-Mayouf
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Alfaisal University, Po Box 3354, 11211, Riyadh, Saudi Arabia.
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4
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Chan EYH, Lai FFY, Ma ALT, Chan TM. Managing Lupus Nephritis in Children and Adolescents. Paediatr Drugs 2024; 26:145-161. [PMID: 38117412 DOI: 10.1007/s40272-023-00609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
Lupus nephritis is an important manifestation of systemic lupus erythematosus, which leads to chronic kidney disease, kidney failure, and can result in mortality. About 35%-60% of children with systemic lupus erythematosus develop kidney involvement. Over the past few decades, the outcome of patients with lupus nephritis has improved significantly with advances in immunosuppressive therapies and clinical management. Nonetheless, there is a paucity of high-level evidence to guide the management of childhood-onset lupus nephritis, because of the relatively small number of patients at each centre and also because children and adolescents are often excluded from clinical trials. Children and adults differ in more ways than just size, and there are remarkable differences between childhood- and adult-onset lupus nephritis in terms of disease severity, treatment efficacy, tolerance to medications and most importantly, psychosocial perspective. In this article, we review the 'art and science' of managing childhood-onset lupus nephritis, which has evolved in recent years, and highlight special considerations in this specific patient population.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, School of Clinical Medicine, Pok Fu Lam, Hong Kong.
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Chandwar K, Aggarwal A. Systemic Lupus Erythematosus in Children. Indian J Pediatr 2023:10.1007/s12098-023-04833-0. [PMID: 37713101 DOI: 10.1007/s12098-023-04833-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease, that mainly affects skin, joints and kidneys but can affect any organ in the body. It is characterized by presence of multiple autoantibodies like ANA, antibodies to dsDNA and RNA associated proteins. The major mechanism leading to tissue damage includes immune complex mediated complement activation, interferon alpha release by plasmacytoid dendritic cells, NETosis by neutrophils as well as defects in monocytes leading to poor clearance of cellular debris and direct cellular dysfunction mediated by antibodies. A child can present with pyrexia of unknown origin, immune mediated cytopenias, malar rash, oral ulcers, serositis, glomerulonephritis or nervous system dysfunction. As renal disease has a bearing on the long term impact, all children should have urine exam and blood pressure measurement done to rule out renal disease. The treatment varies depending on the severity and organs involved. In life or organ threatening situations, pulse methylprednisolone is used. Hydroxychloroquine, Mycophenolate mofetil, Azathioprine and Cyclophosphamide are the commonly used drugs in SLE. Over the years the prognosis of SLE has improved probably due to early diagnosis and better use of immunosuppressive treatment, regular follow up and treatment of co-morbidities. The 10-year survival now approaches 90% and with advent of new and targeted therapy it is hoped that the morbidity and organ damage can also be minimized.
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Affiliation(s)
- Kunal Chandwar
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, Uttar Pradesh, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, Uttar Pradesh, India.
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Lupu VV, Butnariu LI, Fotea S, Morariu ID, Badescu MC, Starcea IM, Salaru DL, Popp A, Dragan F, Lupu A, Mocanu A, Chisnoiu T, Pantazi AC, Jechel E. The Disease with a Thousand Faces and the Human Microbiome-A Physiopathogenic Intercorrelation in Pediatric Practice. Nutrients 2023; 15:3359. [PMID: 37571295 PMCID: PMC10420997 DOI: 10.3390/nu15153359] [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: 06/29/2023] [Revised: 07/18/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Numerous interrelationships are known in the literature that have the final effect of unmasking or influencing various pathologies. Among these, the present article aims to discuss the connection between systemic lupus erythematosus (SLE) and the human microbiome. The main purpose of this work is to popularize information about the impact of dysbiosis on the pathogenesis and evolutionary course of pediatric patients with SLE. Added to this is the interest in knowledge and awareness of adjunctive therapeutic means that has the ultimate goal of increasing the quality of life. The means by which this can be achieved can be briefly divided into prophylactic or curative, depending on the phase of the condition in which the patient is. We thus reiterate the importance of the clinician acquiring an overview of SLE and the human microbiome, doubled by in-depth knowledge of the physio-pathogenic interactions between the two (in part achieved through the much-studied gut-target organ axes-brain, heart, lung, skin), with the target objective being that of obtaining individualized, multimodal and efficient management for each individual patient.
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Affiliation(s)
- Vasile Valeriu Lupu
- Pediatrics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | | | - Silvia Fotea
- Clinical Medical Department, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
| | - Ionela Daniela Morariu
- Faculty of Pharmacy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Minerva Codruta Badescu
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Pediatrics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Delia Lidia Salaru
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alina Popp
- Pediatrics Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Felicia Dragan
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Ancuta Lupu
- Pediatrics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adriana Mocanu
- Pediatrics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Tatiana Chisnoiu
- Pediatrics Department, Faculty of Medicine, Ovidius University, 900470 Constanta, Romania
| | | | - Elena Jechel
- Pediatrics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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7
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Kostik M, Kalashnikova E, Rinat R, Isupova E, Gaidar E, Soloviev AA, Masalova V, Snegireva L, Kornishina T, Abramova N, Suspitsin E, Sorokina L, Kaneva M, Dubko MF, Lubimova N, Kuchuinskaya E, Kalashnikova O, Chasnyk V. Rituximab Biosimilar BCD020 Shows Superior Efficacy above Conventional Non-Biologics Treatment in Pediatric Lupus Nephritis: The Data of Retrospective Cohort Study. Biomedicines 2023; 11:biomedicines11051503. [PMID: 37239173 DOI: 10.3390/biomedicines11051503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Pediatric lupus nephritis (LN) is one of the most serious manifestations of systemic lupus erythematosus (SLE) in children, determining the outcomes of the disease. There are no standardized treatment protocols for pediatric LN, and the role of biologics has not yet been conclusively defined. OBJECTIVES analyze the safety and efficacy of rituximab biosimilar BCD020 in pediatric patients with lupus nephritis. METHODS in a retrospective cohort study, the data from the case histories of 25 patients with LN (10 boys and 15 girls) with an onset age of 13 (9-16) years, who failed conventional non-biologic treatment or developed corticosteroid dependence/toxicity, were included. The diagnosis was made using Systemic Lupus International Collaborating Clinics (SLICC) classification criteria. Rituximab biosimilar BCD020 was prescribed in a dosage of 375 mg/m2 every week (2-4 infusions) with repeated courses every 6-12 months (2-4 infusions) according to disease activity, B-cell depletion, and IgG levels. The dynamics of clinical and laboratory data, the activity of the disease by SLEDAI, and corticosteroid doses were assessed at the onset and during the rituximab trial. RESULTS The main patient's characteristics were: Pre-rituximab non-biologic conventional treatment included: cyclophosphamide 15 (60%), MMF 8 (32%), azathioprine 3 (12%), hydroxychloroquine 12 (48%), and pulse therapy of methylprednisolone followed by oral methylprednisolone 25 (100%). The time before rituximab was 7.0 (3.0-24.0) months, and the whole observation period was 7.0 (0; 24) months. The initial pre-rituximab treatment slightly reduced SLEDAI levels and the proportion of patients with LN. A significant reduction of SLEDAI, the anti-dsDNA level, proteinuria, hematuria, C4 complement, ESR, and the median corticosteroid dose by 80% from the initial value, as well as the proportion of patients without corticosteroids, was observed after rituximab administration. Two deaths were observed due to catastrophic SLE with macrophage activation syndrome, accompanied by a severe infection (invasive aspergillosis, n = 2). Three patients developed serious adverse events: pneumonia (n = 2), transient agranulocytosis (n = 1) after the third rituximab infusion, and meningitis, caused by Listeria monocytosis, after the first rituximab infusion. Eight patients received antibacterial treatment for different respiratory infections without hospital admissions. CONCLUSIONS Rituximab biosimilar BCD020 showed effectiveness in LN, whereas previous non-biologic treatment was insufficiently effective. Randomized controlled trials are required to evaluate the efficacy and safety of rituximab and evaluate the benefits when compared with conventional SLE treatment.
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Affiliation(s)
- Mikhail Kostik
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
- Almazov National Medical Research Centre, 197341 Saint Petersburg, Russia
| | - Elvira Kalashnikova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Raupov Rinat
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Eugenia Isupova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Ekaterina Gaidar
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Anton A Soloviev
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Vera Masalova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Ludmila Snegireva
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Tatyana Kornishina
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Natalia Abramova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Evgeny Suspitsin
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
- N.N. Petrov National Research Center of Oncology, 197758 Saint Petersburg, Russia
| | - Lubov Sorokina
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Maria Kaneva
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Margarita F Dubko
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Natalia Lubimova
- Almazov National Medical Research Centre, 197341 Saint Petersburg, Russia
| | | | - Olga Kalashnikova
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
| | - Vyacheslav Chasnyk
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, 194100 Saint Petersburg, Russia
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8
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Khandelwal P, Govindarajan S, Bagga A. Management and outcomes in children with lupus nephritis in the developing countries. Pediatr Nephrol 2023; 38:987-1000. [PMID: 36255555 DOI: 10.1007/s00467-022-05769-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/14/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lupus nephritis (LN) has variable prevalence, severity, and outcomes across the world. OBJECTIVES This review compares the outcomes of childhood LN in low- and middle-income countries (LMICs) and high-income countries (HICs) and aims to summarize long-term outcomes of pediatric LN from LMICs. DATA SOURCES A systematic literature search, conducted in PubMed, EMBASE, and Cochrane database in the last 30-years from January 1992, published in the English language, identified 113 studies including 52 from lower (n = 1336) and upper MICs (n = 3014). STUDY ELIGIBILITY CRITERIA Cohort studies or randomized controlled trials, of patients ≤ 18 years of age (or where such data can be separately extracted), with > 10 patients with clinically or histologically diagnosed LN and outcomes reported beyond 12 months were included. PARTICIPANTS AND INTERVENTIONS Patients ≤ 18 years of age with clinically or histologically diagnosed LN; effect of an intervention was not measured. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently extracted data. We separately analyzed studies from developed countries (high income countries; HIC) and developing countries (LMICs). Middle-income countries were further classified as lower and upper MICs. Meta-analyses of data were performed by calculating a pooled estimate utilizing the random-effects model. Test for heterogeneity was applied using I2 statistics. Publication bias was assessed using funnel plots. RESULTS Kidney remission was similar across MICs and HICs with 1-year pooled complete remission rates of 59% (95% CI 51-67%); one third of patients had kidney flares. The pooled 5-year survival free of stage 5 chronic kidney disease (CKD5) was lower in MICs, especially in lower MICs compared to HICs (83% vs. 93%; P = 0.002). The pooled 5-year patient survival was significantly lower in MICs than HICs (85% vs. 94%; P < 0.001). In patients with class IV LN, the 5-and 10-year respective risk of CKD5 was 14% and 30% in MICs; corresponding risks in HICs were 8% and 17%. Long-term data from developing countries was limited. Sepsis (48.8%), kidney failure (14%), lupus activity (18.1%), and intracranial hemorrhage/infarct (5.4%) were chief causes of death; mortality due to complications of kidney failure was more common in lower MICs (25.6%) than HICs (6.4%). LIMITATIONS The review is limited by heterogenous approach to diagnosis and management that has changed over the period spanning the review. World Bank classification based on income might not correlate with the standards of medical care. The overall quality of evidence is low since included studies were chiefly retrospective and single center. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Challenges in LMICs include limited access to pediatric nephrology care, dialysis, increased risk of infection-induced mortality, lack of frequent monitoring, and non-compliance due to cost of therapy. Attention to these issues might update the existing data and improve patient follow-up and outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2022 number: CRD42022359002, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359002.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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9
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Kalashnikova EM, Raupov RK, Lyubimova NA, Kuchinskaya EM, Masalova VV, Isupova EA, Gaidar EV, Dubko MF, Snegireva LS, Sorokina LS, Kornishina TL, Kaneva MA, Chikova IA, Likhacheva TS, Kolobova OL, Kalashnikova OV, Chasnyk VG, Kostik MM. The experience of rituximab therapy in patients with juvenile systemic lupus erythematosus: the preliminary results of two-center cohort study. ROSSIYSKIY VESTNIK PERINATOLOGII I PEDIATRII (RUSSIAN BULLETIN OF PERINATOLOGY AND PEDIATRICS) 2023. [DOI: 10.21508/1027-4065-2023-68-1-74-84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Systemic lupus erythematosus is an immunopathological disease which is characterized by a poor prognosis. Biologics applied in the disease treatment allow reducing the corticosteroid toxicity and controlling the disease.Purpose. To evaluate the efficacy and safety of rituximab therapy in children with systemic lupus erythematosus.Material and methods. The retrospective study included data of 48 patients with systemic lupus erythematosus treated with rituximab. Systemic lupus erythematosus was diagnosed based on the SLICC classification criteria. Patients were assessed at baseline disease status, at the time of rituximab initiation and follow-up. The indications for the rituximab were: lupus nephritis, CNS involvement, and hematological involvement resistant to the standard therapy, and in cases of severe corticosteroid toxicity.Results. During rituximab therapy the significant decrease of the SELENA–SLEDAI activity index was observed. There was a significant decrease of the level of antibodies against dsDNA, normalization of the levels of hemoglobin, ESR, complement C4. The proportion of patients with cytopenia decreased up to their complete absence in patients receiving therapy for three years. The number of patients with active lupus nephritis decreased from 16 at the time of rituximab initiation to 1 after 3 years of therapy. Significant dynamics of proteinuria and hematuria was noted, except for 1 patient. The daily dose of corticosteroids was reduced by 90% from baseline in patients treated for 3 years. Serious adverse events included three deaths in patients with high systemic lupus erythematosus activity with uncontrolled macrophage activation syndrome associated with infections. Various infectious complications, hypogammaglobulinemia, which required replacement therapy with intravenous immunoglobulin, were also recorded.Conclusion. Rituximab can be considered as an option for the treatment of severe forms of systemic lupus erythematosus which are resistant to standard therapy. Further studies are required to evaluate efficacy and safety.
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Affiliation(s)
| | - R. K. Raupov
- Saint Petersburg State Pediatric Medical University; Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery
| | | | | | | | | | - E. V. Gaidar
- Saint Petersburg State Pediatric Medical University
| | - M. F. Dubko
- Saint Petersburg State Pediatric Medical University
| | | | | | | | - M. A. Kaneva
- Saint Petersburg State Pediatric Medical University
| | | | | | | | | | | | - M. M. Kostik
- Saint Petersburg State Pediatric Medical University; Almazov National Medical Research Center
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10
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Smith EMD, Lythgoe H, Hedrich CM. Current views on lupus in children. Curr Opin Rheumatol 2023; 35:68-81. [PMID: 36286724 DOI: 10.1097/bor.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This manuscript provides an update on clinical and pathophysiological features of juvenile-onset systemic lupus erythematosis (jSLE), challenges applying adult-derived classification criteria, and recent advances in treatment and care. RECENT FINDINGS Significant scientific advances have improved the understanding of genetic factors (both genetic causes and risk alleles) and associated phenotypic features. Panels of urine/blood biomarker candidates aid in diagnosing jSLE, monitoring disease activity and predicting treatment response. Available classification criteria have been extensively assessed, with differences in clinical and immunological phenotypes of patients across age groups and ethnicities affecting their performance in jSLE. Therapeutic options remain limited and are based on protocols for adult-onset SLE patients. International efforts to inform development of a treat-to-target (T2T) approach for jSLE have yielded cohort-level evidence that target attainment reduces the risk of severe flare and new damage, and treatment compliance. SUMMARY Recent studies have significantly improved our understanding of jSLE pathogenesis, highlighting important differences between jSLE and adult SLE, and providing the basis of biomarker development and target-directed individualized treatment and care. Future work focused on development of a T2T approach in jSLE is eagerly awaited.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Manchester Children's NHS Foundation Trust, Manchester, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool
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11
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Rojas-Rivera JE, García-Carro C, Ávila AI, Espino M, Espinosa M, Fernández-Juárez G, Fulladosa X, Goicoechea M, Macía M, Morales E, Porras LFQ, Praga M. Consensus document of the Spanish Group for the Study of the Glomerular Diseases (GLOSEN) for the diagnosis and treatment of lupus nephritis. Nefrologia 2023; 43:6-47. [PMID: 37211521 DOI: 10.1016/j.nefroe.2023.05.006] [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: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 05/23/2023] Open
Abstract
A significant number of patients with systemic lupus erythematosus (between 20% and 60% according to different reported series) develop lupus nephritis in the course of its evolution, which directly influences their quality of life and vital prognosis. In recent years, the greater knowledge about the pathogenesis of systemic lupus and lupus nephritis has allowed relevant advances in the diagnostic approach and treatment of these patients, achieving the development of drugs specifically aimed at blocking key pathogenic pathways of the disease. Encouragingly, these immunomodulatory agents have shown in well-powered, randomized clinical trials good clinical efficacy in the medium-term, defined as proteinuria remission and preservation of kidney function, with an acceptable safety profile and good patient tolerability. All this has made it possible to reduce the use of corticosteroids and other potentially more toxic therapies, as well as to increase the use of combined therapies. The present consensus document carried out by the Glomerular Diseases Working Group of the Spanish Society of Nephrology (GLOSEN), collects in a practical and summarized, but rigorous way, the best currently available evidence about the diagnosis, treatment, and follow-up of lupus nephritis patients, including cases of special situations, with the main objective of providing updated information and well-founded clinical recommendations to treating physicians, to improve the diagnostic and therapeutic approach to our patients.
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Affiliation(s)
- Jorge E Rojas-Rivera
- Hospital Universitario Fundación Jiménez Díaz, Servicio de Nefrología e Hipertensión, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Servicio de Nefrología, Madrid, Spain.
| | - Clara García-Carro
- Hospital Universitario Clínico San Carlos, Servicio de Nefrología. Madrid, Spain.
| | - Ana I Ávila
- Hospital Dr. Peset, Servicio de Nefrología, Valencia, Spain
| | - Mar Espino
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain
| | - Mario Espinosa
- Hospital Universitario Reina Sofía, Servicio de Nefrología, Cordoba, Spain
| | | | - Xavier Fulladosa
- Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Servicio de Nefrología, Barcelona, Spain
| | - Marian Goicoechea
- Hospital Universitario Gregorio Marañón, Servicio de Nefrología, Madrid, Spain
| | - Manuel Macía
- Hospital Universitario Nuestra Señora de la Candelaria, Servicio de Nefrología, Tenerife, Spain
| | - Enrique Morales
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
| | - Luis F Quintana Porras
- Hospital Clínic de Barcelona, Servicio de Nefrología, Barcelona, Spain; Departamento de Medicina, Universidad de Barcelona, IDIBAPS, Servicio de Nefrología, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
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12
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Documento de consenso del Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) para el diagnóstico y tratamiento de la nefritis lúpica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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13
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Roberts JE, Berbert L, Chang J, Son MBF. Association of Race and Ethnicity With Medication Use for Pediatric Lupus in the Childhood Arthritis and Rheumatology Research Alliance Registry. ACR Open Rheumatol 2022; 4:954-963. [DOI: 10.1002/acr2.11494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/06/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jordan E. Roberts
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Laura Berbert
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Joyce Chang
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
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14
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Velázquez-Guevara A, Abud-Mendoza C. Standard glucocorticoid doses in children with lupus nephritis. Are they convenient? Lupus 2022; 31:1157-1158. [PMID: 35675333 DOI: 10.1177/09612033221106364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander Velázquez-Guevara
- Hospital Central y Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - Carlos Abud-Mendoza
- Hospital Central y Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
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15
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Sun L, Shen Q, Gong Y, Li Y, Lv Q, Liu H, Zhao F, Yu H, Qiu L, Li X, He X, Chen Y, Xu Z, Xu H. Safety and efficacy of telitacicept in refractory childhood-onset systemic lupus erythematosus: A self-controlled before–after trial. Lupus 2022; 31:998-1006. [PMID: 35499216 DOI: 10.1177/09612033221097812] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To observe the efficacy and safety of telitacicept in refractory childhood-onset systemic lupus erythematosus (cSLE). Methods A self-controlled before–after trial. Children with active SLE, aged 5–18 years, who cannot tolerate side effects of glucocorticoid, were enrolled in our study. Patients received subcutaneous injection of telitacicept weekly based on the standard treatment. SLE responder index-4 (SRI-4) was assessed before the first administration and at least 4 weeks after the first administration. Results Among the 15 cases of refractory cSLE, three were males (20%) and 12 were females (80%). The median age and weight were 13 years old and 52 kg, respectively. The median duration of disease was 30 months. 5–26 weeks (80 or 160 mg per week) after administration of telitacicept, 66.7% ( n=10) reached SRI-4 response. 12 cases reduced their glucocorticoid intake from 40 mg/d to 17.5 mg/d. The urinary protein after treatment declined in 8 cases whose 24-h proteinuria was >0.5 g at baseline. The urinary protein in two of the eight cases turned negative and plasma albumin in five of the eight cases rose to normal. In addition, three of these eight cases demonstrated varying degrees of improvement in renal impairment, whose estimated glomerular filtration rate (eGFR, ml/min·1.73 m2) rose from 17.4 to 26.6, 40.7 to 48.2, and 63.2 to 146.0, respectively. There were mild to moderate adverse events after treatment. Conclusion Telitacicept combined with the standard treatment may significantly increase the SRI-4 response rate and reduce the glucocorticoid dosage in refractory cSLE, and also shown efficacy on lupus nephritis. The related adverse drug events were controllable.
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Affiliation(s)
- Li Sun
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yinv Gong
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yifan Li
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Qianying Lv
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Haimei Liu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Fei Zhao
- Department of Nephrology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Lingzhi Qiu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Xiaozhong Li
- Department of Nephrology and Rheumatology, Children’s Hospital of Soochow University, Jiangsu, China
| | - Xiaoliang He
- Department of Rheumatology, Children’s Hospital of Fudan University Anhui Hospital, Anhui, China
| | - Yuqing Chen
- Department of Rheumatology, Children’s Hospital of Fudan University Anhui Hospital, Anhui, China
| | - Zhiquan Xu
- Department of Nephrology and Rheumatology, Children’s Hospital of Fudan University at Hainan, Hainan, China
| | - Hong Xu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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16
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Nikolopoulos D, Fotis L, Gioti O, Fanouriakis A. Tailored treatment strategies and future directions in systemic lupus erythematosus. Rheumatol Int 2022; 42:1307-1319. [PMID: 35449237 DOI: 10.1007/s00296-022-05133-0] [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: 03/07/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
Abstract
Systemic lupus erythematosus (SLE) represents a diagnostic and therapeutic challenge for physicians due to its protean manifestations and unpredictable course. The disease may manifest as multisystemic or organ-dominant and severity at presentation may vary according to age at onset (childhood-, adult- or late-onset SLE). Different manifestations may respond variably to different immunosuppressive medications and, even within the same organ-system, the severity of inflammation may vary from mild to organ-threatening. Current "state-of-the-art" in SLE treatment aims at remission or low disease activity in all organ systems. Apart from hydroxychloroquine and glucocorticoids (which should be used with caution), the choice of the appropriate immunosuppressive agent should be individualized and depend on the prevailing manifestation, severity stratification and patient childbearing potential. In this review, we provide an overview of therapeutic options for the various organ manifestations and severity patterns of the disease, different phenotypes (such as multisystem versus organ-dominant disease), as well as specific considerations, including lupus with antiphospholipid antibodies, childhood and late-onset disease, as well as treatment options during pregnancy and lactation.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.
| | - Lampros Fotis
- Department of Pediatrics, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece
| | - Ourania Gioti
- Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.,1st Department of Propaedeutic Internal Medicine, "Laikon" General Hospital, Medical School National Kapodistrian University of Athens, Athens, Greece
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