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Tur C, Eckstein M, Velden J, Rauber S, Bergmann C, Auth J, Bucci L, Corte G, Hagen M, Wirsching A, Grieshaber-Bouyer R, Reis P, Kittan N, Wacker J, Rius Rigau A, Ramming A, D'Agostino MA, Hartmann A, Müller F, Mackensen A, Bozec A, Schett G, Raimondo MG. CD19-CAR T-cell therapy induces deep tissue depletion of B cells. Ann Rheum Dis 2024:ard-2024-226142. [PMID: 39153835 DOI: 10.1136/ard-2024-226142] [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: 05/21/2024] [Accepted: 08/01/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVES CD19-targeting chimeric antigen receptor (CAR) T-cell therapy can induce long-term drug-free remission in patients with autoimmune diseases (AIDs). The efficacy of CD19-CAR T-cell therapy is presumably based on deep tissue depletion of B cells; however, such effect has not been proven in humans in vivo. METHODS Sequential ultrasound-guided inguinal lymph node biopsies were performed at baseline and after CD19-CAR T-cell therapy in patients with AIDs. Results were compared with lymph node biopsies from rituximab (RTX)-treated AID patients with absence of peripheral B cells. Conventional and immunohistochemistry staining were performed on lymph node tissue to assess architecture as well the number of B cells, follicular dendritic cells (FDCs), plasma cells, T cells and macrophages. RESULTS Sequential lymph node biopsies were analysed from five patients with AID before and after CD19-CAR T-cell therapy and from five patients with AID after RTX treatment. In addition, non-lymphoid organ biopsies (colon, kidney and gallbladder) from three additional patients with AID after CD19-CAR T-cell therapy were analysed. CD19+ and CD20+ B cells were completely depleted in the lymph nodes after CD19-CAR T-cell therapy, but not after RTX treatment. Plasma cells, T cells and macrophages in the lymph nodes remained unchanged. Follicular structures were disrupted and FDCs were depleted in the lymph nodes after CD19-CAR T-cell therapy, but not after RTX. Non-lymphoid organs were completely depleted of B cells. DISCUSSION This study demonstrates complete B-cell depletion in secondary lymphoid tissues of patients with AIDs following CD19-CAR T-cell therapy combined with standard lymphodepleting therapy.
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Affiliation(s)
- Carlo Tur
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
- Division of Rheumatology-Fondazione Policlinico Universitario A. Gemelli, IRCCS-Università Cattolica del Sacro Cuore, Roma, Lazio, Italy
| | - Markus Eckstein
- Institute of Pathology and Comprehensive Cancer Center EMN, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
| | - Joachim Velden
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
| | - Simon Rauber
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Christina Bergmann
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Janina Auth
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Laura Bucci
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Giulia Corte
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Melanie Hagen
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Andreas Wirsching
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Ricardo Grieshaber-Bouyer
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Petra Reis
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Nicolai Kittan
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Jochen Wacker
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Aleix Rius Rigau
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Andreas Ramming
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Maria-Antonietta D'Agostino
- Division of Rheumatology-Fondazione Policlinico Universitario A. Gemelli, IRCCS-Università Cattolica del Sacro Cuore, Roma, Lazio, Italy
| | - Arndt Hartmann
- Institute of Pathology and Comprehensive Cancer Center EMN, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
| | - Fabian Müller
- Department of Medicine 5-Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) and Uniklinikum Erlangen, Erlangen, Bayern, Germany
| | - Andreas Mackensen
- Department of Medicine 5-Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) and Uniklinikum Erlangen, Erlangen, Bayern, Germany
| | - Aline Bozec
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Georg Schett
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
- Division of Rheumatology-Fondazione Policlinico Universitario A. Gemelli, IRCCS-Università Cattolica del Sacro Cuore, Roma, Lazio, Italy
| | - Maria Gabriella Raimondo
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Uniklinikum Erlangen, Erlangen, Germany, Erlangen, Germany
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Suszek D, Dubaj M, Bigosiński K, Dembowska A, Kaniewski M, Sielwanowska W, Skierkowski B, Dzikowska I, Sieczka J, Majdan M. Usefulness in daily practice of the Systemic Lupus Erythematosus Disease Activity Index 2000 scale and the Systemic Lupus Erythematosus Disease Activity Score index for assessing the activity of systemic lupus erythematosus. Reumatologia 2024; 62:187-195. [PMID: 39055730 PMCID: PMC11267658 DOI: 10.5114/reum.2024.141291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by high heterogeneity of clinical manifestations and an uncertain prognosis. Although the mortality rate due to SLE has decreased significantly in recent decades, there is still a need to find good tools to measure disease activity for early detection of exacerbations and treatment planning. Over the decades, more than a dozen disease activity scales/indicators have been developed, with the SLE Disease Activity Index (SLEDAI) being the most popular. More recently, the new SLE Disease Activity Score (SLE-DAS) has been introduced. This paper compares the two methods of assessing SLE activity, and presents the relevance of these scales in pregnant SLE patients and their use in formulating definitions of remission and low disease activity. The results show that the SLEDAI and the SLE-DAS are of comparable value in assessing SLE activity and complement each other.
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Affiliation(s)
- Dorota Suszek
- Chair and Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Maciej Dubaj
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Karol Bigosiński
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Aleksandra Dembowska
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Marcin Kaniewski
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Wiktoria Sielwanowska
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Bartosz Skierkowski
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Izabela Dzikowska
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Julia Sieczka
- Student Scientific Circle at the Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
| | - Maria Majdan
- Chair and Department of Rheumatology and Connective Tissue Diseases, Medical University, Lublin, Poland
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Fan L, Tang Z, He X, He X, Zhang Z, Juliao P. Real-world effectiveness of belimumab in patients with lupus in China: RELIABLE observational cohort study protocol. Lupus Sci Med 2024; 11:e001144. [PMID: 38991834 PMCID: PMC11243130 DOI: 10.1136/lupus-2024-001144] [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: 01/04/2024] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The efficacy of belimumab in SLE has been demonstrated in randomised clinical trials, and its real-world effectiveness has been shown in studies in several countries. While belimumab was approved for treating SLE in China in 2019, data on its benefit in clinical practice are limited. This study will evaluate belimumab's effectiveness in China, using practical clinical measures, such as Lupus Low Disease Activity State (LLDAS), to add to the body of real-world evidence. METHODS AND ANALYSIS The Real-world Effectiveness of beLImumAB in patients with systemic Lupus Erythematosus in China (RELIABLE) is an ambidirectional, observational descriptive cohort study across approximately 15 centres in China. Adults with SLE newly initiating belimumab with ≥1 measure of all five LLDAS components (SLE Disease Activity Index-2000; no new lupus disease activity; Physician Global Assessment; prednisolone-equivalent dose; immunosuppressants/biologics use) in the 3 months preceding belimumab initiation (index date) will be eligible and retrospectively and/or prospectively enrolled, depending on data availability. The retrospective follow-up will be ≤6 months, and retrospective and prospective patients will have a maximum 24-month follow-up. The primary objectives will be to describe the proportion of patients achieving LLDAS at 12 and 24 months post-index. The key secondary objective will be to describe the proportion of patients achieving LLDAS and each component at 3, 6, 9 and 18 months post-index. All data will be analysed descriptively; a statistical estimand will be applied to account for intercurrent events expected in a real-world setting. ETHICS AND DISSEMINATION This study will comply with all applicable laws regarding patient privacy; institutional review board approval will be obtained before the study commencement. CONCLUSIONS This study will evaluate belimumab's effectiveness in patients with SLE initiating belimumab in clinical practice in China. Using LLDAS will provide clinicians with valuable insights into the impact of belimumab on the treat-to-target strategy with a relevant measure that can be repeated across the clinical practice.
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Affiliation(s)
| | | | | | | | - Zhuoli Zhang
- Peking University First Hospital, Beijing, China
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Saraiva L, Cunha RN, Jesus D, Gatto M, Zen M, Iaccarino L, da Silva JAP, Doria A, Inês LS. The SLE-DAS provides an accurate and feasible flare tool in the clinical setting: a validation study. Rheumatology (Oxford) 2024; 63:1123-1129. [PMID: 37458482 DOI: 10.1093/rheumatology/kead353] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/30/2023] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To assess the criterion validity of the SLE disease activity score (SLE-DAS) flare tool and compare its performance in identifying flares against other instruments. METHODS Patients with SLE fulfilling SLE-DAS low disease activity at baseline were included from two academic lupus clinics. During follow-up, flares were identified by the senior attending clinician, applying the expert-consensus-based definition as gold-standard. The first clinical flare from flaring patients, and the first visit after baseline in patients without flares were analysed. In each no flare/flare visits, we assessed flares by SLE-DAS (score increase ≥1.72), classic-SELENA Flare Index (c-SELENA FI), revised-SELENA FI (r-SELENA FI), and SLEDAI-2K (score increase ≥4). We estimated the sensitivity, specificity, and Cohen's Kappa agreement of each flare tool against the gold-standard. RESULTS A total of 442 patients were included and followed-up for 22.9 (14.2) months. Incidence of flares was 8.19/100 patient-years, with 69 patients experiencing flares. The SLE-DAS identified 96.6% of the expert-defined flares implying a treatment change and classified 28.0% of those as moderate/severe. Sensitivity and specificity for the gold-standard flare definition were: SLE-DAS 97.1% and 97.3%, c-SELENA FI 88.4% and 98.1%, r-SELENA FI 88.4% and 96.8%, SLEDAI-2K 56.5% and 99.2%, respectively. Kappa coefficients of these instruments were 0.902 (95% CI: 0.847, 0.957), 0.870 (95% CI: 0.805, 0.935), 0.832 (95% CI: 0.761, 0.903), and 0.663 (95% CI: 0.557, 0.769), respectively. The number of flare misclassifications was lowest with the SLE-DAS, and highest with the SLEDAI-2K. CONCLUSION The SLE-DAS accurately identifies and categorizes flares as mild or moderate/severe. It is feasible and, thus, may help the physicians' treatment decisions in the clinical practice setting.
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Affiliation(s)
- Liliana Saraiva
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rita N Cunha
- Rheumatology Department, Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - José A P da Silva
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research-ICBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Luís Sousa Inês
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
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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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Inês LS, Fredi M, Jesus D, Shumilova A, Franceschini F, Vital EM. What is the best instrument to measure disease activity in SLE? - SLE-DAS vs Easy BILAG. Autoimmun Rev 2024; 23:103428. [PMID: 37634675 DOI: 10.1016/j.autrev.2023.103428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 08/29/2023]
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous condition making assessment of disease activity challenging. However, thorough assessment is essential to evaluate patients longitudinally, to guide therapeutic decisions, and for clinical trials. Currently, the most popular disease activity index in clinical practice and trials is SLEDAI-2K. Its main advantage is ease of use, but significant weaknesses of SLEDAI-2K are omission of several serious manifestations, inability to capture change within an organ system, and fixed severity weightings that are often inappropriate. Recently several groups have developing improved tools. We report here the debate held at CORA meeting on this issue. SLE-DAS includes 17 weighted clinical and laboratory parameters including continuous measures in 4 items with an online calculator. A higher sensitivity to change compared to SLEDAI-2K has been demonstrated in its validation studies. Easy BILAG is an improved format of the BILAG-2004 that retains its content but greatly simplified. Its scoring using a single-page form that incorporates concise definitions for key terms next to clinical items. Easy-BILAG demonstrates higher accuracy and less variability and increased and better user feedback compared to the standard BILAG-2004 format. Both the indices discussed at CORA showed an advantage in measuring disease activity compared to SLEDAI.
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Affiliation(s)
- Luís Sousa Inês
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal; CHUC Lupus Clinic, Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Micaela Fredi
- Rheumatology and Clinical Immunology Unit and Clinical and Experimental Science Department ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Diogo Jesus
- Faculty of Health Sciences, Universidade da Beira Interior, Covilhã, Portugal; Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Anastasiia Shumilova
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit and Clinical and Experimental Science Department ASST Spedali Civili and University of Brescia, Brescia, Italy.
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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Shumilova A, Vital EM. Musculoskeletal manifestations of systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2023; 37:101859. [PMID: 37620235 DOI: 10.1016/j.berh.2023.101859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023]
Abstract
MSK is the most common and impactful symptom of lupus at a population level. It has a variety of different presentations, but joint swelling is often not present despite imaging-proven synovitis. Imaging with US and MRI has been shown to improve detection of inflammation and identify treatment-responsive patients. In contrast, the SLEDAI shows poor sensitivity, specificity, and responsiveness. While BILAG and SLE-DAS are superior, they are still less accurate than imaging. These issues may explain why the evidence for conventional and biologic therapies for MSK lupus is complex. In clinical practice, physicians must take care not to underestimate MSK inflammation and consider using imaging. Future research should investigate new therapeutic targets specifically for synovitis and more sensitive outcome measures and trials to evaluate them.
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Affiliation(s)
- Anastasiia Shumilova
- University of Leeds, Leeds, United Kingdom; V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
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Cruciani C, Zen M, Gatto M, Morand E, Doria A. Assessment of disease activity and damage in SLE: Are we there yet? Best Pract Res Clin Rheumatol 2023; 37:101896. [PMID: 38044231 DOI: 10.1016/j.berh.2023.101896] [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: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023]
Abstract
Systemic Lupus Erythematosus is a systemic autoimmune disease characterized by a great heterogenicity in course and clinical manifestations. Although prognosis improved in the last decades of the 20th century, mortality remains higher than in the general population and uncontrolled disease activity and therapy-related adverse effects have been identified as major contributors to damage accrual and poor outcomes. Assessment of disease activity and damage in SLE represents a great challenge even to the expert rheumatologist. Global disease activity indices are tools developed to assess activity across multiple organ systems. Several disease activity indices have been developed over the years, each with its own strengths and weaknesses, and knowing them is essential for understanding research studies, such as clinical trials, in which they are used. Organ-specific activity indices have been developed concurrently to represent organ involvement such as glomerulonephritis, cutaneous and musculoskeletal lupus manifestations. Regarding damage, the SLICC/ACR damage index has proven to be an effective tool for damage accrual assessment, yet not devoid of drawbacks. This review provides an overview of the most frequently utilized indices developed for the assessment of activity and damage in SLE highlighting their pros and cons when applied to the research and clinical setting.
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Affiliation(s)
- Claudio Cruciani
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Margherita Zen
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
| | - Mariele Gatto
- Rheumatology Unit, Department of Clinical and Biological Sciences, University of Turin and Turin Mauriziano Hospital, Turin, Italy.
| | - Eric Morand
- Centre for Inflammatory Diseases, Monash University, Rheumatology Unit, Monash Health, Melbourne, Australia.
| | - Andrea Doria
- Division of Rheumatology, Department of Internal Medicine, Azienda Ospedaliera di Padova, University of Padova, Padova, Veneto, Italy.
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Koo M, Lu MC. Performance of a New Instrument for the Measurement of Systemic Lupus Erythematosus Disease Activity: The SLE-DAS. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2097. [PMID: 38138199 PMCID: PMC10744780 DOI: 10.3390/medicina59122097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease that affects multiple organ systems and manifests in a relapsing-remitting pattern. Consequently, it is paramount for rheumatologists to assess disease activity, identify flare-ups, and establish treatment goals for patients with SLE. In 2019, the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) was introduced as a novel tool for measuring disease activity. This tool refines the parameters of the established SLE Disease Activity Index 2000 (SLEDAI-2K) to enhance the assessment process. This review aims to provide an introduction to the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) and summarizes research on its development, its comparison with existing disease activity measures, and its performance in clinical settings. Literature searches on PubMed using the keyword "SLE-DAS" were conducted, covering publications from March 2019 to September 2023. Studies that compared SLE-DAS with other SLE disease activity measurement tools were reviewed. Findings indicated that SLE-DAS consistently performs on par with, and sometimes better than, traditional measures in assessing clinically meaningful changes, patient improvement, disease activity, health-related quality of life, hospitalization rates, and disease flare-ups. The association between SLE-DAS and mortality rates among patients with SLE, however, remains to be further explored. Although SLE-DAS is a promising and potentially effective tool for measuring SLE disease activity, additional research is needed to confirm its effectiveness and broaden its clinical use.
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Affiliation(s)
- Malcolm Koo
- Department of Nursing, Tzu Chi University of Science and Technology, Hualien 970302, Taiwan;
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Ming-Chi Lu
- Division of Allergy, Immunology and Rheumatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 622401, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
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10
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Aringer M, Leuchten N. [Assessment tools for systemic lupus erythematosus]. Z Rheumatol 2023:10.1007/s00393-023-01359-w. [PMID: 37188996 DOI: 10.1007/s00393-023-01359-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/17/2023]
Abstract
A systematic assessment is critical for taking advantage of the current options for optimizing systemic lupus erythematosus (SLE) management. Without regular SLE activity measurements, treat to target and remission are empty words, and the EULAR recommendations therefore insist on these assessments. They rely on activity scores, such as SLEDAI, ECLAM and BILAG or more recently, EasyBILAG and SLE-DAS. Assessment is completed by organ-specific measurement methods and the evaluation of damage. In the study setting the classification criteria and combined endpoints for clinical testing are crucial, as is measurement of the quality of life. This review article provides an overview of the current state of SLE assessments.
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Affiliation(s)
- Martin Aringer
- Bereich Rheumatologie, Medizinische Klinik und Poliklinik III und UniversitätsCentrum für Autoimmun- und Rheumatische Erkrankungen (UCARE), Universitätsklinikum und medizinische Fakultät Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Nicolai Leuchten
- Bereich Rheumatologie, Medizinische Klinik und Poliklinik III und UniversitätsCentrum für Autoimmun- und Rheumatische Erkrankungen (UCARE), Universitätsklinikum und medizinische Fakultät Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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11
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Banjari M, Touma Z, Gladman DD. Improving measures of disease activity in systemic lupus erythematosus. Expert Rev Clin Immunol 2023; 19:193-202. [PMID: 36503376 DOI: 10.1080/1744666x.2023.2156339] [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: 12/14/2022]
Abstract
INTRODUCTION Systemic lupus erythematosus (SLE) is a multisystem disease with varied manifestations and course. Variation in presentation among patients, and within the same patient, there may be varied manifestations over time. It has been difficult to measure the extent of disease activity accurately. Several investigators and groups have developed definitions of disease activity and methods to measure it. Consequently, there are currently several instruments to measure disease activity as well as damage in patients with SLE. AREAS COVERED This review covers currently available evidence on measures of disease activity in SLE. It discusses potential avenues for further development of new measures and the refinement of existing tools to improve disease activity measures in research and clinical care settings. EXPERT OPINION Given the complexity and heterogeneity of the disease, further work and tools are needed to assess disease activity better. Organ-specific measures for cutaneous, renal, and joint manifestations are needed for a detailed assessment of disease activity in conjunction with the use of disease generic tools (e.g. SLEDAI). New tools such as the SLE Disease Activity Index-Glucocorticoid Index (SLEDAI-2 KG) incorporating glucocorticoid doses to describe disease activity, SLE-DAS and SLEDAI-2 K RI-50 to record partial improvements could also be helpful.
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Affiliation(s)
- Maher Banjari
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zahi Touma
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Dvisiion of Rheumatology, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Dafna D Gladman
- Division of Rheumatology, University of Toronto, Lupus Clinic, Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada.,Dvisiion of Rheumatology, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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12
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Ali S, Garcia C, Fasano S, Raine C, Wincup C. How can we accurately measure disease activity during pregnancy in systemic lupus erythematosus? New insights from the BILAG-2004 Pregnancy Index. Rheumatol Adv Pract 2023; 7:rkad024. [PMID: 36874268 PMCID: PMC9976887 DOI: 10.1093/rap/rkad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/18/2023] Open
Affiliation(s)
| | | | - Serena Fasano
- Rheumatology Unit, Department of Precision Medicine, University of Campania, “Luigi Vanvitelli”, Naples, Italy
| | - Charles Raine
- Department of Rheumatology, Division of Medicine, University College London, London, UK
| | - Chris Wincup
- Correspondence to: Chris Wincup, Department of Rheumatology, Division of Medicine, University College London, Room 422, 4th Floor Rayne Building, 5 University Street, London WC1E 6JF, UK. E-mail:
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13
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Samões B, Zen M, Abelha-Aleixo J, Gatto M, Doria A. Caveats and pitfalls in defining low disease activity in systemic lupus erythematosus. Autoimmun Rev 2022; 21:103165. [PMID: 35931316 DOI: 10.1016/j.autrev.2022.103165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
The treat-to-target strategy has been recently suggested in the management of Systemic Lupus Erythematosus (SLE). Lupus Low Disease Activity State (LLDAS) and Definitions Of Remission In SLE (DORIS) remission were outlined as two concentric targets. The achievement of LLDAS was shown to be associated with lower frequency of SLE flare, decreased damage progression, better quality of life, and reduced mortality. In addition, LLDAS has successfully been tested in post-hoc analyses of a number of randomized controlled trials. However, it has been recently underlined that LLDAS includes a high proportion of patients in remission, raising the question if these endpoints are sufficiently distinct to consider their separation clinically relevant. Some studies suggest that the protective effect of LLDAS on damage might be due to the inclusion of patients who are in remission. Notably, clinical low disease activity (LDA) seems to be uncommon in SLE due to the relapsing-remitting pattern of the disease, in which low level of activity only occurs transiently. Moreover, since the domains included in LLDAS have several limitations, such as the use of a binomial disease activity index, the exclusion of some mild manifestations and the consideration of items subjected to variability (physician global assessment and glucocorticoids dose), not all patients in LDA are adequately represented by LLDAS.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Joana Abelha-Aleixo
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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Connelly K, Morand EF. Easy-BILAG: as easy as ABC? Rheumatology (Oxford) 2022; 61:3879-3880. [PMID: 35171270 DOI: 10.1093/rheumatology/keac062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton, Australia.,Department of Rheumatology, Monash Health, Clayton, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton, Australia.,Department of Rheumatology, Monash Health, Clayton, Australia
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