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Aggarwal A, Fernandes TAP, Migowa A, Smith EMD, Hanif M, Webb K, Lewandowski LB. Childhood-Onset Systemic Lupus Erythematosus (cSLE): An International Perspective. Curr Allergy Asthma Rep 2024; 24:559-569. [PMID: 39145903 PMCID: PMC11377481 DOI: 10.1007/s11882-024-01169-3] [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] [Accepted: 07/25/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE OF REVIEW Childhood-onset systemic lupus erythematosus (cSLE) is a severe and potentially life-threatening chronic autoimmune disease. cSLE is more aggressive and has poorer outcomes than adult-onset disease. The global burden of cSLE is poorly understood, with most publications on cSLE originating from high-resourced settings. The reports from less resourced settings indicate high morbidity and mortality in these populations. RECENT FINDINGS In this article, we review the disparities in global access to rheumatology care and research for patients with cSLE. We highlight recent cSLE advances from all regions of the globe. We describe current obstacles to cSLE clinical care and research in all settings. Finally, we propose a path forward for high quality, equitable and accessible care to individuals with cSLE everywhere. Individuals with cSLE are at risk for morbidity and death, yet patients worldwide face challenges to adequate access to care and research. Sustained, collaborative efforts are needed to create pathways to improve care and outcomes for these patients.
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Affiliation(s)
- Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Taciana A P Fernandes
- Department of Pediatrics, Medical School, São Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Angela Migowa
- Department of Paediatrics and Child Health, Aga Khan University, 3Rd Parklands Avenue, P.O.BOX 30270 00100 GPO, Nairobi, Kenya
| | - Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Maria Hanif
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Kate Webb
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Laura B Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA.
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Jones SA, Morand EF. Targeting Interferon Signalling in Systemic Lupus Erythematosus: Lessons Learned. Drugs 2024; 84:625-635. [PMID: 38807010 PMCID: PMC11196297 DOI: 10.1007/s40265-024-02043-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
The development of new medicines for systemic lupus erythematosus (SLE) has not addressed unmet clinical need, with only three drugs receiving regulatory approval for SLE in the last 60 years, one of which was specifically licensed for lupus nephritis. In the last 20 years it has become clear that activation of type 1 interferons (IFN) is reproducibly detected in the majority of SLE patients, and the actions of IFN in the immune system and on target tissues is consistent with a pathogenic role in SLE. These findings led to considerable drug discovery activity, first with agents directly targeting IFN family cytokines, with results that were encouraging but underwhelming. In contrast, targeting the type I IFN receptor with the monoclonal antibody anifrolumab, thereby blocking all IFN family members, was effective in a phase II clinical trial. This led to a pair of phase III trials, one of which was negative and the other positive, reflecting the difficulty of obtaining outcomes from trials in this complex disease. Nonetheless, the balance of evidence resulted in approval of anifrolumab in multiple jurisdictions from 2021 onwards. Multiple approaches to targeting the type 1 IFN pathway have subsequently had positive phase II clinical trials, including antibodies targeting cells that produce IFN, and small molecules targeting the receptor kinase TYK2, required for IFN signalling. Despite multiple hurdles, it is clear that IFN targeting in SLE is here to stay. The story of IFN-targeting therapy in SLE has lessons for drug development overall in this disease.
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Affiliation(s)
- Sarah A Jones
- Centre for Inflammatory Disease, Monash University, Clayton, Australia
| | - Eric F Morand
- Centre for Inflammatory Disease, Monash University, Clayton, Australia.
- Department of Rheumatology, Monash Health, Melbourne, Australia.
- Monash Medical Centre, 246 Clayton Rd, Clayton, VIC, 3168, Australia.
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Hoi A, Igel T, Mok CC, Arnaud L. Systemic lupus erythematosus. Lancet 2024; 403:2326-2338. [PMID: 38642569 DOI: 10.1016/s0140-6736(24)00398-2] [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] [Received: 06/21/2023] [Revised: 09/28/2023] [Accepted: 02/25/2024] [Indexed: 04/22/2024]
Abstract
Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease characterised by the presence of autoantibodies towards nuclear antigens, immune complex deposition, and chronic inflammation at classic target organs such as skin, joints, and kidneys. Despite substantial advances in the diagnosis and management of SLE, the burden of disease remains high. It is important to appreciate the typical presentations and the diagnostic process to facilitate early referral and diagnosis for patients. In most patients, constitutional, mucocutaneous, and musculoskeletal symptoms represent the earliest complaints; these symptoms can include fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. In this Seminar we will discuss a diagnostic approach to symptoms in light of the latest classification criteria, which include a systematic evaluation of clinical manifestations (weighted within each domain) and autoantibody profiles (such as anti-double-stranded DNA, anti-Sm, hypocomplementaemia, or antiphospholipid antibodies). Non-pharmacotherapy management is tailored to the individual, with specific lifestyle interventions and patient education to improve quality of life and medication (such as hydroxychloroquine or immunosuppressant) adherence. In the last decade, there have been a few major breakthroughs in approved treatments for SLE and lupus nephritis, such as belimumab, anifrolumab, and voclosporin. However the disease course remains variable and mortality unacceptably high. Access to these expensive medications has also been restricted across different regions of the world. Nonetheless, understanding of treatment goals and strategies has improved. We recognise that the main goal of treatment is the achievement of remission or low disease activity. Comorbidities due to both disease activity and treatment adverse effects, especially infections, osteoporosis, and cardiovascular disease, necessitate vigilant prevention and management strategies. Tailoring treatment options to achieve remission, while balancing treatment-related comorbidities, are priority areas of SLE management.
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Affiliation(s)
- Alberta Hoi
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Talia Igel
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases, INSERM UMR-S 1109, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Morand EF, Jones SA. Flare in Systemic Lupus Erythematosus: Lost in Translation? J Rheumatol 2024; 51:437-439. [PMID: 38428956 DOI: 10.3899/jrheum.2024-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Eric F Morand
- E.F. Morand, MBBS, PhD, Sub-Faculty of Clinical and Molecular Medicine, Monash University, and Director, Rheumatology, Monash Health;
| | - Sarah A Jones
- S.A. Jones, PhD, Rheumatology Research Laboratory, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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Yang Y, Zhang X, Jing L, Xiao Y, Gao Y, Hu Y, Jia S, Zhou G, Xiong H, Dong G. MDSC-derived S100A8/9 contributes to lupus pathogenesis by promoting TLR7-mediated activation of macrophages and dendritic cells. Cell Mol Life Sci 2024; 81:110. [PMID: 38429401 PMCID: PMC10907481 DOI: 10.1007/s00018-024-05155-w] [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] [Revised: 01/17/2024] [Accepted: 02/04/2024] [Indexed: 03/03/2024]
Abstract
Toll-like receptors (TLRs), especially TLR7, play an important role in systemic lupus erythematosus (SLE) pathogenesis. However, the regulatory mechanism underlying the abnormal activation of TLR pathways in patients with SLE has not been elucidated. Notably, accumulating evidence indicates that myeloid-derived suppressor cells (MDSCs) are important regulators of inflammation and autoimmune diseases. Compared with healthy control subjects, patients with SLE have a greater proportion of MDSCs among peripheral blood mononuclear cells (PBMCs); however, the effect of MDSCs on TLR7 pathway activation has not been determined. In the present study, lupus MDSCs significantly promoted TLR7 pathway activation in macrophages and dendritic cells (DCs), exacerbating the imiquimod-induced lupus model. RNA-sequencing analysis revealed significant overexpression of S100 calcium-binding protein A8 (S100A8) and S100A9 in MDSCs from diseased MRL/lpr mice. In vitro and in vivo studies demonstrated that S100A8/9 effectively promoted TLR7 pathway activation and that S100A8/9 deficiency reversed the promoting effect of MDSCs on TLR7 pathway activation in lupus. Mechanistically, MDSC-derived S100A8/9 upregulated interferon gamma (IFN-γ) secretion by macrophages and IFN-γ subsequently promoted TLR7 pathway activation in an autocrine manner. Taken together, these findings suggest that lupus MDSCs promote TLR7 pathway activation and lupus pathogenesis through the S100A8/9-IFN-γ axis. Our study identified an important target for SLE therapy.
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Affiliation(s)
- Yonghong Yang
- Medical Research Center, Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China
| | - Xin Zhang
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Lina Jing
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Yucai Xiao
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Yangzhe Gao
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Yuxin Hu
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Shujiao Jia
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China
| | - Guangxi Zhou
- Medical Research Center, Affiliated Hospital of Jining Medical University, Jining, 272029, Shandong, China.
| | - Huabao Xiong
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China.
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, 272067, Shandong, China.
| | - Guanjun Dong
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, 272067, Shandong, China.
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, 272067, Shandong, China.
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Arnaud L, Parodis I, Devilliers H, Chasset F. Clinical trial outcomes for SLE: what we have and what we need. Lupus Sci Med 2024; 11:e001114. [PMID: 38360028 PMCID: PMC10875561 DOI: 10.1136/lupus-2023-001114] [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: 11/27/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024]
Abstract
The paradigm of drug approval in SLE currently relies on successful large phase III randomised controlled trials and a set of primary, secondary and additional end points. Taken together, these outcomes offer a nuanced understanding of the efficacy and safety of the investigational agent. In this review, we thoroughly examine the main outcomes used in SLE trials and highlight unmet requirements as well as potential venues for future trial design in SLE. Disease activity indices can be broadly categorised into global-specific and organ-specific indices, in particular for skin, joints and kidneys, but there is no universal consensus about their use in clinical trials. Because each of these instruments has its own intrinsic strengths and weaknesses, the assessment of treatment response has progressed from relying solely on one individual disease activity index to using composite responder definitions. Those are typically measured from the trial baseline to the end point assessment date and may be combined with the need to taper and maintain glucocorticoids (GCs) within prespecified ranges. Remission and low disease activity are two critical states in the perspective of 'Treat-to-Target' trials, but are not fully recognised by regulators. While significant progress has been made in clinical trial outcomes for SLE, there is a clear need for continued innovation. Addressing these challenges will require collaboration between researchers, clinicians, patients as well as with regulatory agencies to refine existing outcome measures, incorporate meaningful and ethnically diverse patient perspectives, foster relevant digital opportunities and explore new therapeutic avenues, including early use of investigational agents. By doing so, we can advance our ability to manage SLE effectively and safely and improve the lives of those living with this complex and impactful autoimmune disease.
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Affiliation(s)
- Laurent Arnaud
- Service de rhumatologie, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Centre National de Référence Maladies Rares Est Sud-Ouest (RESO), Strasbourg, France
| | - Ioannis Parodis
- Service de rhumatologie, Institut Karolinska, Stockholm, Sweden
| | - Hervé Devilliers
- Servide de Médecine interne, CHU Dijon - Bourgogne, Hôpital F. MITTERRAND, Dijon, France
| | - Francois Chasset
- Sorbonne Université, Faculté de médecine, AP-HP, Service de Dermatologie et Allergologie, Hôpital Tenon, and INSERM U1135, Paris, France
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Tian J, Kang S, Zhang D, Huang Y, Yao X, Zhao M, Lu Q. Selection of indicators reporting response rate in pharmaceutical trials for systemic lupus erythematosus: preference and relative sensitivity. Lupus Sci Med 2023; 10:e000942. [PMID: 37798046 PMCID: PMC10565300 DOI: 10.1136/lupus-2023-000942] [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: 04/07/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE SLE is a common multisystem autoimmune disease with chronic inflammation. Many efficacy evaluation indicators of randomised clinical trials (RCTs) for SLE have been proposed but the comparability remains unknown. We aim to explore the preference and comparability of indicators reporting response rate and provide basis for primary outcome selection when evaluating the efficacy of SLE pharmaceutical treatment. METHODS We systematically searched three databases and three registries to identify pharmacological intervention-controlled SLE RCTs. Relative discriminations between indicators were assessed by the Bayesian hierarchical linear mixed model. RESULTS 33 RCTs met our inclusion criteria and we compared eight of the most commonly used indicators reporting response rate. SLE Disease Activity Index 4 (SLEDAI-4) and SLE Responder Index 4 were considered the best recommended indicators reporting response rate to discriminate the pharmacological efficacy. Indicator preference was altered by disease severity, classification of drugs and outcome of trials, but SLEDAI-4 had robust efficacy in discriminating ability for most interventions. Of note, BILAG Index-based Combined Lupus Assessment showed efficacy in trials covering all-severity patients, as well as non-biologics RCTs. The British Isles Lupus Assessment Group response and Physician's Global Assessment response were more cautious in evaluating disease changes. Serious adverse event was often applied to evaluate the safety and tolerability of treatments rather than efficacy. CONCLUSIONS The impressionable efficacy discrimination ability of indicators highlights the importance of flexibility and comprehensiveness when choosing primary outcome(s). As for trials that are only evaluated by SLEDAI-4, attention should be paid to outcome interpretation to avoid the exaggeration of treatment efficacy. Further subgroup analyses are limited by the number of included RCTs. PROSPERO REGISTRATION NUMBER CRD42022334517.
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Affiliation(s)
- Jingru Tian
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, Jiangsu, China
| | - Shuntong Kang
- Department of Dermatology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Dingyao Zhang
- Graduate Program in Biological and Biomedical Sciences, Yale University, New Haven, Connecticut, USA
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, USA
| | - Yaqing Huang
- Department of Pathology, Yale University, New Haven, Connecticut, USA
| | - Xu Yao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Ming Zhao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, Jiangsu, China
| | - Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, Jiangsu, China
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