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Kostopoulou M, Mukhtyar CB, Bertsias G, Boumpas DT, Fanouriakis A. Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations. Ann Rheum Dis 2024:ard-2023-225319. [PMID: 38777375 DOI: 10.1136/ard-2023-225319] [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: 11/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To analyse the new evidence (2018-2022) for the management of systemic lupus erythematosus (SLE) to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations. METHODS Systematic literature reviews were performed in the Medline and the Cochrane Library databases capturing publications from 1 January 2018 through 31 December 2022, according to the EULAR standardised operating procedures. The research questions focused on five different domains, namely the benefit/harm of SLE treatments, the benefits from the attainment of remission/low disease activity, the risk/benefit from treatment tapering/withdrawal, the management of SLE with antiphospholipid syndrome and the safety of immunisations against varicella zoster virus and SARS-CoV2 infection. A Population, Intervention, Comparison and Outcome framework was used to develop search strings for each research topic. RESULTS We identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomised controlled trials (RCTs) documented the efficacy of the type 1 interferon receptor inhibitor, anifrolumab, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN), when compared with standard of care. For the treatment of specific organ manifestations outside LN, a lack of high-quality data was documented. Multiple observational studies confirmed the beneficial effects of attaining clinical remission or low disease activity, reducing the risk for multiple adverse outcomes. Two randomised trials with some concerns regarding risk of bias found higher rates of relapse in patients who discontinued glucocorticoids (GC) or immunosuppressants in SLE and LN, respectively, yet observational cohort studies suggest that treatment withdrawal might be feasible in a subset of patients. CONCLUSION Anifrolumab and belimumab achieve better disease control than standard of care in extrarenal SLE, while combination therapies with belimumab and voclosporin attained higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favourable long-term outcomes. In patients achieving these targets, GC and immunosuppressive therapy may gradually be tapered. Cite Now.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete, School of Medicine, Heraklion, Greece
- Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Pitsigavdaki S, Nikoloudaki M, Garantziotis P, Silvagni E, Repa A, Marangoni A, Flouri I, Avgoustidis N, Parperis K, Fanouriakis A, Govoni M, Sidiropoulos P, Boumpas DT, Bortoluzzi A, Bertsias G. Pragmatic targets for moderate/severe SLE and their implications for clinical care and trial design: sustained DORIS or LLDAS for at least 6 months is sufficient while their attainment for at least 24 months ensures high specificity for damage-free progression. Ann Rheum Dis 2024; 83:464-474. [PMID: 38233103 PMCID: PMC10958283 DOI: 10.1136/ard-2023-224919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVES Treatment targets in systemic lupus erythematosus (SLE) have been validated in unselected-in terms of severity-cohorts, which limits their generalisability. We assessed remission (Definition of Remission in SLE (DORIS)) and Lupus Low Disease Activity State (LLDAS) in a historical cohort of 348 patients with active moderate-to-severe disease and median follow-up of 5 years. METHODS Active SLE was defined as Physician Global Assessment ≥1.5 and/or SLE Disease Activity Index 2000 ≥6, requiring therapy intensification. DORIS/LLDAS, organ damage, flares and adverse events were monitored. Shared frailty survival, generalised linear models and K-means clustering were applied. RESULTS Sustained DORIS and LLDAS for ≥6 months occurred in 41.1% and 80.4%, respectively, and resulted in reduced damage accrual (HR: 0.58; 95% CI 0.36 to 0.93 and 0.61; 0.43 to 0.86) and severe flares (HR: 0.14; 0.08 to 0.27 and 0.19; 0.13 to 0.27). LLDAS without DORIS was also protective (HR: 0.65; 0.43 to 0.98 for damage, 0.49; 0.36 to 0.67 for flares). Models fitting increasing duration of targets showed that DORIS ≥50% and LLDAS ≥60% of time, or alternatively, ≥24 and ≥36 months, achieved optimal balance between feasibility (20.2-41.7%) and specificity (73.3-86.1%) for damage-free outcome. These targets were linked to reduced serious adverse events (risk ratio (RR): 0.56-0.71), hospitalisation (RR: 0.70) and mortality (RR: 0.06-0.13). Patients with predominant arthritis and mucocutaneous disease experienced reduced DORIS/LLDAS, compared with counterparts with major organ involvement. Conventional drugs were more frequently used in the former group, whereas potent immunosuppressive/biological agents in the latter. CONCLUSIONS In moderate-to-severe SLE, sustained DORIS/LLDAS for at least 6 months is sufficient, while attainment for at least 24 months ensures higher specificity for damage-free progression, thus facilitating treat-to-target strategies and clinical trials. Arthritis and skin disease represent unmet therapeutic needs that could benefit from novel biologics.
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Affiliation(s)
- Sofia Pitsigavdaki
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Myrto Nikoloudaki
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Panagiotis Garantziotis
- Laboratory of Autoimmunity and Inflammation, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg and University Hospital of Erlangen, Erlangen, Germany
| | - Ettore Silvagni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Argyro Repa
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Antonio Marangoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Irini Flouri
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Nestor Avgoustidis
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
| | - Konstantinos Parperis
- Division of Rheumatology, Department of Medicine, University of Cyprus Medical School, Nicosia, Cyprus
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - Prodromos Sidiropoulos
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
- Division of Immunity, Institute of Molecular Biology and Biotechnology-Foundation for Research and Technology - Hellas (FORTH), Heraklion, Greece
| | - Dimitrios T Boumpas
- Laboratory of Autoimmunity and Inflammation, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alessandra Bortoluzzi
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, Italy
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, Greece
- Division of Immunity, Institute of Molecular Biology and Biotechnology-Foundation for Research and Technology - Hellas (FORTH), Heraklion, Greece
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Parra Sánchez AR, van Vollenhoven RF, Morand EF, Bruce IN, Kandane-Rathnayake R, Weiss G, Tummala R, Al-Mossawi H, Sorrentino A. Targeting DORIS Remission and LLDAS in SLE: A Review. Rheumatol Ther 2023; 10:1459-1477. [PMID: 37798595 PMCID: PMC10654283 DOI: 10.1007/s40744-023-00601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
Remission is the established therapeutic goal for patients with systemic lupus erythematosus (SLE) and is currently defined by the widely adopted Definition Of Remission In SLE (DORIS) criteria. Attainment of remission is rare in the clinical setting, thus an alternative, pragmatic treatment target of low disease activity, as defined by the Lupus Low Disease Activity State (LLDAS), provides a less stringent and more attainable treatment goal for a wider proportion of patients compared with DORIS remission. Randomized controlled trials and real-world analyses have confirmed the positive clinical benefits of achieving either DORIS remission or LLDAS. The treat-to-target (T2T) approach utilizes practical clinical targets to proactively tailor individual treatment regimens. Studies in other chronic inflammatory diseases using the T2T approach demonstrated significantly improved clinical outcomes and quality-of-life measures compared with established standard of care. However, such trials have not yet been performed in patients with SLE. Here we review the evolution of DORIS remission and LLDAS definitions and the evidence supporting the positive clinical outcomes following DORIS remission or LLDAS attainment, before discussing considerations for implementation of these outcome measures as potential T2T objectives. Adoption of DORIS remission and LLDAS treatment goals may result in favorable patient outcomes compared with established standard of care for patients with SLE.
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Affiliation(s)
- Agner R Parra Sánchez
- Amsterdam Rheumatology Center ARC, Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.
| | - Ronald F van Vollenhoven
- Amsterdam Rheumatology Center ARC, Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Eric F Morand
- Sub-Faculty of Clinical and Molecular Medicine, Monash University, Clayton, VIC, Australia
| | - Ian N Bruce
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Gudrun Weiss
- Global Medical Affairs, Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Raj Tummala
- Clinical Development, Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Hussein Al-Mossawi
- Clinical Development, Late Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Alessandro Sorrentino
- Global Medical Affairs, Respiratory and Immunology, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
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Tanaka Y. Viewpoint on anifrolumab in patients with systemic lupus erythematosus and a high unmet need in clinical practice. RMD Open 2023; 9:e003270. [PMID: 37597847 PMCID: PMC10441065 DOI: 10.1136/rmdopen-2023-003270] [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: 04/28/2023] [Accepted: 07/23/2023] [Indexed: 08/21/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterised by unpredictable flares. Many patients with SLE are unable to achieve the recommended treatment goal of remission or the intermediate, yet still clinically beneficial, goal of Lupus Low Disease Activity State (LLDAS) with standard of care (SoC) treatments. LLDAS is an emerging treat-to-target goal in SLE with the aim of reducing organ damage and mortality. A high unmet need remains in SLE and mainstay glucocorticoid treatment is associated with unacceptable toxicity. The recently approved type I interferon receptor antagonist anifrolumab is a new treatment option for this historically underserved patient population. In phase 3 trials, a higher percentage of patients on anifrolumab achieved remission, as defined by the Definition Of Remission In SLE (DORIS), and LLDAS compared with placebo. Real-world clinical experience with anifrolumab use is still limited. Until real-world study results and updated treatment guidelines are available, personal expert clinical experience supported by data may inform clinical decision-making. This viewpoint article discusses four example patient types that could be considered for anifrolumab treatment based on (1) high-risk features early in the disease course, (2) inability to achieve and (3) maintain at least LLDAS, or (4) a desire to reduce or stop SoC. These patients with high unmet need may benefit from the addition of anifrolumab to SoC to achieve or maintain the therapeutic goals of LLDAS or DORIS remission.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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Kisaoglu H, Baba O, Kalyoncu M. Lupus low disease activity state as a treatment target for pediatric patients with lupus nephritis. Pediatr Nephrol 2023; 38:1167-1175. [PMID: 36156735 DOI: 10.1007/s00467-022-05742-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lupus low disease activity state (LLDAS) is a treatment target for patients with SLE and is associated with decreased risk for severe flare and new damage. We investigated the utility of the achievement of LLDAS in children with lupus nephritis and whether attainment of LLDAS is associated with more favorable outcomes. METHODS Data of children, diagnosed with biopsy-proven lupus nephritis between January 2012 and December 2020, were retrospectively analyzed. RESULTS For patients who did not achieve LLDAS after initial treatment (first 6 months), presence of autoimmune hemolytic anemia (62% vs. 18%, p = 0.047), anti-Sm (85% vs. 18%, p = 0.003) and anti-dsDNA (77% vs. 27%, p = 0.038) antibodies, proliferative lupus nephritis (77% vs. 27%, p = 0.038), and hypertension (69% vs. 9%, p = 0.005) at onset were more frequently encountered. Also, a lower rate of complete kidney response (43% vs. 100%, p = 0.005) and a higher rate of hypertension (86% vs. 13%, p = 0.002) were observed in patients who did not achieve LLDAS-50, defined as being in LLDAS at least 50% of the observation time. Attainment of both LLDAS after initial treatment and LLDAS-50 were associated with lower rates of kidney flare (p = 0.001 and p = 0.002, respectively) and damage accrual (p = 0.007 and p = 0.02, respectively) through the observation period. CONCLUSIONS LLDAS is an attainable treatment target for children with lupus nephritis and associated with lower rates of kidney flare and damage. Presence of hematologic involvement, hypertension, and proliferative lupus nephritis at onset adversely influenced the early achievement of LLDAS. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Hakan Kisaoglu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.
| | - Ozge Baba
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Mukaddes Kalyoncu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.,Division of Pediatric Nephrology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
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