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Roccatello D, Sciascia S, Rossi D, Fenoglio R. Refractory Systemic Lupus Erythematosus: Identification and Pharmacological Management. Drugs 2023; 83:117-134. [PMID: 36729344 DOI: 10.1007/s40265-022-01824-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is characterized by an aberrant immune response, leading to an extremely heterogeneous clinical presentation, potentially affecting different systems and organs. Despite the fact that SLE mortality has greatly decreased since the introduction of steroids, some forms of refractory/severe SLE still have the potential to result in permanent organ damage as well as increased mortality and morbidity. Furthermore, SLE patients with multiple comorbidities may face a clinical conundrum and have a bad prognosis. An improved prognosis for severe refractory SLE depends on prompt and appropriate treatment. Due to the scarcity of solid data from a well-characterized group of patients with refractory/severe SLE coming from randomized controlled studies, this review aims to shed light on this with real-world evidence from clinical research performed at our Unit, the University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID) (Turin, Italy). In order to determine the key clinical and prognostic features, and therapeutic approaches for severe and/or refractory SLE, our experience will be described together with existing literature, primarily focused on dermatological, neuropsychiatric, and renal symptoms.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
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Ji L, Gao D, Hao Y, Huang H, Wang Y, Deng X, Geng Y, Zhang Z. Low-dose glucocorticoids withdrawn in systemic lupus erythematosus: a desirable and attainable goal. Rheumatology (Oxford) 2022; 62:181-189. [PMID: 35412598 DOI: 10.1093/rheumatology/keac225] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/11/2022] [Accepted: 04/05/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To assess the risk of flare in systemic lupus erythematosus (SLE) patients after low-dose glucocorticoid (GC) discontinuation and to evaluate the risk factors of flare. METHODS SLE patients who ever discontinued GCs were identified from the Peking University First Hospital SLE cohort. The disease flare profile after GC discontinuation was analysed. The flare rate was analysed using Kaplan-Meier analysis. Cox regression was used to determine the effects of variables on SLE flare. A prognostic nomogram using Cox proportional hazards regression modelling was developed. RESULTS A total of 132 SLE patients were eligible for the final analysis. They were followed up for a median of 21.8 months (interquartile range 9.01-36.7). The cumulative probability of flare after GC discontinuation was 8.3% at 6 months, 16.8% at 1 years and 27.5% at 2 years. In multivariate Cox analysis, hypocomplementemia and serologically active clinically quiescent (SACQ) were independent risk factors of flare [hazard ratio (HR0 2.53 (95% CI 1.32, 4.88); HR 3.17 (95% CI 1.44, 6.97), respectively]. Age ≥40 years at GC withdrawal and hydroxychloroquine (HCQ) usage were independent protective factors of flare [HR 0.53 (95% CI 0.29, 0.99); HR 0.32 (95% CI 0.17, 0.62), respectively]. The protective effect of HCQ was dosage related. From the perspective of different tapering strategies embodied as the duration from prednisone 5 mg/day to complete discontinuation, a slower tapering strategy (12-24 months) significantly reduced the risk of flare compared with a faster tapering strategy (<3 months) [HR 0.30 (95% CI 0.11, 0.82), P = 0.019]. The prognostic nomogram including the aforementioned factors effectively predicted the 1 and 2 year probability of being flare-free. CONCLUSION Low-dose GC is feasibly discontinued in real-life settings. SACQ and younger age are potential risk factors of SLE flare, while HCQ use and slow GC tapering to withdrawal can reduce relapse. The visualized model we developed may help to predict the risk of flare among SLE patients who discontinued GC.
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Affiliation(s)
- Lanlan Ji
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Dai Gao
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Hong Huang
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Xuerong Deng
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Yan Geng
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
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Porta SV, Ugarte-Gil MF, García-de la Torre I, Bonfá E, Gómez-Puerta JA, Arnaud L, Cardiel MH, Alarcón GS, Pons-Estel BA, Pons-Estel G. Controversies in Systemic Lupus Erythematosus: Are We Treating Our Patients Adequately? J Clin Rheumatol 2022; 28:e651-e658. [PMID: 34897194 DOI: 10.1097/rhu.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.
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Affiliation(s)
- Sabrina Valeria Porta
- From the Rheumatology Department, J. M. Ramos Mejía Hospital, Buenos Aires, Argentina
| | - Manuel F Ugarte-Gil
- Universidad Científica del Sur, Hospital Guillermo Almenara Irigoyen, EsSalud, Lima, Perú
| | - Ignacio García-de la Torre
- Department of Immunology and Rheumatology, Hospital General de Occidente de la Secretaría de Salud, Universidad de Guadalajara, Guadalajara, México
| | - Eloísa Bonfá
- Division of Rheumatology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, National Reference Center for Rare Auto-immune and Systemic Diseases (CRMR RESO); Strasbourg, France
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, Mich, México
| | - Graciela S Alarcón
- Division of Rheumatology and Clinical Immunology, The University of Alabama at Birmingham, Birmingham, AL; Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo Pons-Estel
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Gao D, Hao Y, Fan Y, Ji L, Zhang Z. Predicting lupus low disease activity state and remission in SLE: novel insights. Expert Rev Clin Immunol 2021; 17:1083-1089. [PMID: 34392757 DOI: 10.1080/1744666x.2021.1968297] [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: 10/20/2022]
Abstract
Introduction:Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with extreme heterogeneity, which sometimes may be life-threatening. Principles of treat to target (T2T) in SLE were put forward more recently, leading to better long-term survival and reduced damage accrual.Areas covered: Lupus low disease activity state (LLDAS) and remission are currently the most widely accepted principal goals of SLE-T2T recommendations. In this article, we will deliver the novel insights into the definitions of LLDAS/remission, attainability, and, most importantly, clinical predictors of LLDAS and remission in SLE.Expert opinion: Since the release of the LLDAS and the framework on definitions of remission in SLE, there has been much evidence of a correlation between target attainment or maintenance and better prognosis. In the meantime, researchers are searching for predictors of target attainment. Noteworthy, prospective randomized trials are lacking worldwide to verify the benefits of T2T in various aspects of SLE. The most essential issue is that the optimal definition of the therapeutic target for SLE remains controversial, particularly regarding the maintenance dose of prednisone, the need for immunosuppressive withdrawal, and the requirement for serologic conversion. How to implement T2T principles in clinical practice also needs further investigation.
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Affiliation(s)
- Dai Gao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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Gao D, Hao Y, Mu L, Xie W, Fan Y, Ji L, Zhang Z. Frequencies and predictors of the Lupus Low Disease Activity State and remission in treatment-naïve patients with systemic lupus erythematosus. Rheumatology (Oxford) 2020; 59:3400-3407. [PMID: 32337549 DOI: 10.1093/rheumatology/keaa120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/11/2020] [Indexed: 01/01/2023] Open
Abstract
Abstract
Objectives
To evaluate the attainability of Lupus Low Disease Activity State (LLDAS) and definitions of remission in SLE (DORIS) in a treatment-naïve cohort of SLE.
Methods
LLDAS5 was defined as LLDAS with a prednisone dose ≤5 mg/day. There were four definitions in DORIS: clinical remission on treatment (RONT), complete RONT, clinical remission off treatment (ROFT) and complete ROFT. The treatment-naïve patients from Peking University First Hospital SLE cohort were enrolled. The time to each state and their annual cumulative probabilities were estimated. The frequencies of patients who achieved each component of LLDAS or DORIS during follow-up were determined. The predictors of time to each state were identified.
Results
A total of 218 patients were included, with a median follow-up of 4.48 years. Respectively, 190 (87.2%), 160 (73.4%), 148 (67.9%), 94 (43.1%), 23 (10.6%) and 18 (8.3%) patients achieved LLDAS, LLDAS5, clinical RONT, complete RONT, clinical ROFT and complete ROFT. The median time to LLDAS, LLDAS5, clinical RONT and complete RONT were 1.4, 2.3, 2.6 and 4.7 years, respectively. Positive anti-dsDNA, RP and anaemia were significantly associated with prolonged time to LLDAS, LLDAS5 or clinical RONT.
Conclusion
Our data confirmed that LLDAS is an attainable early treatment target for SLE. Though with more difficulty, RONT can be achieved in two-thirds of our patients. ROFT may not be an ideal treatment target at present as it is only attained in few patients.
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Affiliation(s)
- Dai Gao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Lin Mu
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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