Accelerated atherosclerosis in systemic lupus erythematosus: implications for patient management

Autoimmune Responses and Therapeutic Interventions for Systemic Lupus Erythematosus: A Comprehensive Review

Systemic Lupus Erythematosus (SLE) or Lupus is a multifactorial autoimmune disease of multiorgan malfunctioning of extremely heterogeneous and unclear etiology that affects multiple organs and physiological systems. Some racial groups and women of childbearing age are more susceptible to SLE pathogenesis. Impressive progress has been made towards a better understanding of different immune components contributing to SLE pathogenesis. Recent investigations have uncovered the detailed mechanisms of inflammatory responses and organ damage. Various environmental factors, pathogens, and toxicants, including ultraviolet light, drugs, viral pathogens, gut microbiome metabolites, and sex hormones trigger the onset of SLE pathogenesis in genetically susceptible individuals and result in the disruption of immune homeostasis of cytokines, macrophages, T cells, and B cells. Diagnosis and clinical investigations of SLE remain challenging due to its clinical heterogeneity and hitherto only a few approved antimalarials, glucocorticoids, immunosuppressants, and some nonsteroidal anti-inflammatory drugs (NSAIDs) are available for treatment. However, the adverse effects of renal and neuropsychiatric lupus and late diagnosis make therapy challenging. Additionally, SLE is also linked to an increased risk of cardiovascular diseases due to inflammatory responses and the risk of infection from immunosuppressive treatment. Due to the diversity of symptoms and treatment-resistant diseases, SLE management remains a challenging issue. Nevertheless, the use of next-generation therapeutics with stem cell and gene therapy may bring better outcomes to SLE treatment in the future. This review highlights the autoimmune responses as well as potential therapeutic interventions for SLE particularly focusing on the recent therapeutic advancements and challenges.

High Burden of Premature Arteriosclerosis on Renal Biopsy Results in Incident Lupus Nephritis

OBJECTIVE

Cardiovascular disease (CVD) is accelerated in patients with systemic lupus erythematosus and lupus nephritis (LN). Despite the literature suggesting that renal arteriosclerosis predicts CVD in other glomerulonephritis diseases, arteriosclerosis grading and reporting might be particularly overlooked in LN biopsies. Our objective was to examine the burden of renal arteriosclerosis in LN and to assess whether arteriosclerosis is underreported in LN biopsies.

METHODS

We identified all patients with LN undergoing kidney biopsy between 1994 and 2017 at an academic center. We interpreted LN biopsy reports to classify the Banff categories of absent, mild, moderate, or severe renal arteriosclerosis. The prevalence of renal arteriosclerosis was compared with the prevalence published for age-matched healthy peers, and predictors of arteriosclerosis were examined. We overread biopsies for Banff renal arteriosclerosis grading and compared to pathology reports.

RESULTS

Among 189 incident patients with LN, renal arteriosclerosis prevalence was 2 decades earlier compared to their healthy peers, affecting 40% of patients ages 31-39 years with LN compared to 44% of healthy peers ages 50-59 years. A multivariable analysis showed a 3-fold higher odds of renal arteriosclerosis in patients ages ≥30 years with LN. LN chronicity on biopsy results predicted a 4-fold higher odds of renal arteriosclerosis. The overreads determined that 50% of standard LN biopsy reports missed reporting the presence or absence of renal arteriosclerosis.

CONCLUSION

Renal arteriosclerosis is accelerated by 2 decades in patients with LN compared to their healthy peers and is overlooked by pathologists in half of the routine biopsy reports. We propose incorporating Banff renal arteriosclerosis grading in all LN biopsy reports.

Predictive values of dyslipidemia and B-type natriuretic peptide levels in juvenile systemic lupus erythematosus: A two center-experience

B-type natriuretic peptide (BNP) is a biomarker that helps in determining the diagnosis and prognosis of heart failure (HF). There is an increased risk for cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) with high disease activity, demonstrated by the higher frequency of dyslipidemia and higher BNP concentrations than in healthy controls. The aim of the work was to evaluate the association between the levels of lipids and BNP in pediatric patients with SLE with HF. We classified our subjects into three groups as follows: Group 1 (active SLE group): included 38 patients who subgrouped into 16 with HF and 22 without HF; Group 2 (inactive SLE group): included 38 patients, and Group 3 (control group): included 38 apparently healthy children. All children were subjected to complete history taking, clinical examination, SLE disease activity index scoring and investigations included complete blood count, erythrocyte sedimentation rate, 24-h urinary protein, anti-double strand deoxy-ribonucleic acid and anti-nuclear antibody, lipid profile, serum albumin, protein, and BNP. There was a significantly elevated lipid level and decreased high-density lipoproteins in lupus patients than in healthy controls. The dyslipidemia was more prevalent in active SLE. There were significantly elevated BNP levels in lupus patients than in healthy controls. In this study, we found that BNP was a biomarker in determining the diagnosis and prognosis of HF. This study revealed that BNP levels were increased in SLE patients without cardiac symptoms as compared to healthy controls; furthermore, the BNP levels were higher in active SLE patients with HF. The data indicated that there is a high risk for CVD in SLE with high disease activity, as demonstrated by the higher frequency of dyslipidemia and higher BNP concentrations than in healthy controls.

Association between ischemic heart disease and systemic lupus erythematosus-a large case-control study

Ischemic heart disease (IHD) is a well identified cause of mortality in systemic lupus erythematosus (SLE) patients due to an accelerated premature atherosclerosis. We investigated the proportion of comorbid IHD among SLE patients derived from a large, national real-life database. Using data from the largest HMO in Israel, the Clalit Health Services, we selected for patients with SLE. These patients were compared with age and sex matched controls with regards to the proportion of IHD in a case-control study. Chi-square and t tests were used for univariate analysis, and a logistic regression model was used for multivariate analysis. The study included 5018 patients with SLE and 25090 age and sex-frequency matched controls. The prevalence of IHD in patients with SLE was increased in comparison to controls (11.3 and 3.1%, P < 0.001). In a multivariate analysis, SLE was associated with IHD (OR 3.77, 95% confidence interval 3.34-4.26). We have confirmed that SLE patients suffer a high prevalence of IHD. Our data supports that SLE is an independent risk factor for IHD. When evaluating by gender, the risk seems even more substantial in females. No significant difference was found in the risk of IHD in SLE among the difference socioeconomic strata.

Management of cardiovascular risk in systemic lupus erythematosus: a systematic review

Systemic lupus erythematosus is associated with accelerated atherosclerosis and increased risk of cardiovascular complications. The aim of this study was to review the effectiveness of interventions for primary and secondary prevention of cardiovascular events and mortality and to review the effectiveness of interventions for cardiovascular risk factor reduction in systemic lupus erythematosus patients. A systematic review was conducted. Electronic databases Medline and Embase (1961-2015) were searched. Nineteen articles met the inclusion criteria and were selected. Low-calorie and/or low glycaemic index calories may be a useful option for secondary prevention in obese patients with systemic lupus erythematosus, and exercise would be useful in improving the endothelial function measured by flow-mediated dilation in this group of patients. The use of lipid-lowering drugs may improve the lipid profile in patients with systemic lupus erythematosus and hyperlipidaemia, but the effect of this treatment on overall cardiovascular mortality remains unknown. Antiplatelets, anticoagulants, antimalarials and lipid-lowering drugs may be effective in the primary and secondary prevention of major cardiovascular events, such as acute myocardial infarction or stroke. Similarly, lipid-lowering drugs and antimalarial drugs appear to reduce the serum levels of total cholesterol, low-density lipoprotein, glucose, diastolic blood pressure and calcium deposition at the coronary arteries. They may also improve insulin resistance and the level of high-density lipoproteins. It appears that treatment with antihypertensive drugs reduces blood pressure in patients with systemic lupus erythematosus, but the available studies are of low quality.

Nonorgan specific autoantibodies and heart damage

Heart damage, mediated by different autoantibodies can involve several anatomical heart structures: valves, arteries, conduction tissue. Verrucous endocarditis is frequently reported in patients with antiphospholipid syndrome (APS) with or without systemic lupus erythematosus (SLE), particularly if they suffer from central nervous system involvement. Antiphospholipid antibodies (aPL) were shown deposited at subendothelial level of the affected valves. According to several in vitro and in vivo experimental models, aPL, anti-oxidized LDL (oxLDL), anti-heat shock protein 65 (HSP65) and anti-endothelial cells antibodies (AECA) seem to be involved in the pathogenesis of the atherosclerosis phenomena described in systemic autoimmune disease and vasculitis. However, the observation of the association of the same antibodies with clinical and subclinical atherosclerosis in patients is still controversial. The children of anti-Ro/SSA positive mothers can be affected by the congenital heart block. Anti Ro/SS-A antibodies play a major pathogenic role in affecting the heart conduction tissue in this rare condition.

Factor V Leiden and Prothrombin G20210A Mutations and the Risk of Atherothrombotic Events in Systemic Lupus Erythematosus

Because genetic predisposition to atherothrombosis in systemic lupus erythematosus (SLE) remains to be determined, the most common genetic prothrombotic factors, prothrombin G20210A and factor V Leiden mutations, were studied. Seventy-four SLE patients with vascular ischemia (SLE cases) were studied and stratified into myocardial infarction and/or cerebrovascular accident subgroup (MI/CVA), and coronary heart disease subgroup without overt arterial thrombotic events (CHD). Seventy-one SLE patients without atherothrombosis were investigated as SLE controls. Factor V Leiden was detected in six cases (five in MI/CVA, one in CHD group) and three controls (OR 2.00, 95%CI 0.48-8.32). Two cases (both CHD patients) had prothrombin G20210A mutation vs. three controls (OR 0.63, 95%CI 0.1-3.88). Anticardiolipin antibodies (aCL) were increased in cases vs. controls (39/74 vs. 27/71); however, this was not statistically significant (OR 1.82, 95%CI 0.94-3.52). Neither univariate nor multivariate analysis indicated that investigated mutations are risk factors for atherothrombosis in SLE cases, MI/CVA, or CHD subgroups. Overall, disease activity was the strongest risk factor for atherothrombosis (p=0.0014) in SLE cases. Combination of disease activity+gender was the best predictor of atherothrombotic process (p=0.00045) in this cohort. In MI/CVA subgroup, disease activity was the only predictor (p=0.0058). In CHD patients, the best predictive value was conferred by combination of hypertension+gender+disease activity (p=0.00077). No other investigated risk factor (including aCL) conferred an increased risk individually or potentiated the other risk factors. The results deny the role of investigated mutations in atherothrombosis in SLE, but they underscore the importance of disease activity (i.e., ongoing inflammation) in pathogenesis of atherosclerosis and arterial thrombosis.

Current and emerging treatment options in the management of lupus

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with variable clinical manifestations. While the clearest guidelines for the treatment of SLE exist in the context of lupus nephritis, patients with other lupus manifestations such as neuropsychiatric, hematologic, musculoskeletal, and severe cutaneous lupus frequently require immunosuppression and/or biologic therapy. Conventional immunosuppressive agents such as mycophenolate mofetil, azathioprine, and cyclophosphamide are widely used in the management of SLE with current more rationalized treatment regimens optimizing the use of these agents while minimizing potential toxicity. The advent of biologic therapies has advanced the treatment of SLE particularly in patients with refractory disease. The CD20 monoclonal antibody rituximab and the anti-BLyS agent belimumab are now widely in use in clinical practice. Several other biologic agents are in ongoing clinical trials. While immunosuppressive and biologic agents are the foundation of inflammatory disease control in SLE, the importance of managing comorbidities such as cardiovascular risk factors, bone health, and minimizing susceptibility to infection should not be neglected.

Evaluation of torsion and twist mechanics of the left ventricle in patients with systemic lupus erythematosus

Objective:

Myocardial involvement in systemic lupus erythematosus (SLE) has great importance. The aim of this study is to evaluate the rotation and twisting mechanics of the left ventricle (LV) in patients with SLE.

Methods:

Forty-three patients fulfilled at least four of the American College of Rheumatology criteria for SLE and 30 individuals as controls were included in the study. SLE disease activity was assessed using the SELENA–SLEDAI score. Echocardiography was performed for all subjects. The patients fulfilled at least four of the American College of Rheumatology criteria for SLE were enrolled in the study. SLE disease activity was assessed using the SELENA-SLEDAI score. Echocardiography was performed for all individuals. Comparisons between groups were made using independent samples t-test with the standard statistical software (SPSS, version 15.0; SPSS Inc., Chicago, IL, USA). Each image was digitally stored for offline analysis. Measurement of global strain assessed by 17-segment model and rotational parameters were performed. LV ejection fraction was calculated by the biplane Simpson's method. Comparisons between groups were made using the independent samples t-test with the standard statistical software. A p value of 0.05 was considered statistically significant.

Results:

The values of mean global longitudinal strain, basal global circumferential strain (GCS), mean basal radial strain, and apical GCS were significantly lower in SLE patients. The difference between basal rotation, apical rotation, twist of the LV, and torsion of the LV in the SLE patients and controls were not significant (8.8±5.5 vs. 10.6±5.8, p=0.183;-4.7±3.0 vs. -4.8±3.2, p=0.947; 11.7±6.4 vs. 13.2±6.4, p=0.366; and 1.8±0.8 vs. 1.9±2.3, p=0.725, respectively). Although there was not any significant relationship between SELENA–SLEDAI score and myocardial strain analyses of the LV, the basal rotation and the torsion of the LV were lower in patients with SLE having a SLEDAI score of ≥17 (p=0.024 for basal rotation and p=0.032 for torsion).

Conclusion:

The number of segmental and global strain analyses were decreased in SLE patients with globally normal LVEF. The twist and torsion mechanics of the LV were preserved according to the control group, and the left ventricular torsion and basal rotation were found to be significantly decreased in those with an activity score of ≥17.

Heart failure with complete recovery in a patient with systemic lupus erythematosus

We report the case of a 43-year-old female patient who was admitted to the Cardiology Department from the Rheumatology Clinic where she was being treated for multi-organ serositis, fatigue and mild dyspnoea on exertion. The patient had a known medical history of systemic lupus erythematosus (SLE). Following extensive evaluation with blood tests for immunological and viral culprits, cardiac ultrasound, chest and abdominal computed tomography (CT) and heart magnetic resonance imaging (MRI), the diagnosis of effusive constrictive pericarditis secondary to her SLE was made. Treatment with β-blockers, diuretics and corticosteroids was given with excellent results, and one year post discharge the patient remains asymptomatic. Systemic lupus erythematosus patients often manifest cardiac complications such as pericarditis. The practising physician should always bear in mind this possibility when treating such patients.

Primary preventive services in patients with systemic lupus erythematosus: study from a population-based sample in Southeast U.S

OBJECTIVES

Systemic lupus erythematosus (SLE) patients are at risk for complications that can be mitigated by appropriate preventive care. We examined the receipt of immunizations, cancer screening, and cardiovascular risk preventive services in a predominantly Black cohort of SLE patients from the Southeast U.S. To identify gaps in primary preventive services (PPS) that might be specific to SLE as opposed to local health system factors, we used as reference a population-based sample from the same area.

METHODS

A cross-sectional design was used to characterize the percentage of PPS received by 751 SLE patients from Atlanta, GA, and 9040 subjects from the same community, of whom 938 had diabetes. Factors associated with the receipt of PPS were examined with multivariable analysis of variance.

RESULTS

Approximately 65% of recommended PPS were provided to the SLE, overall community (OC), and diabetes samples. However, only 22.5%, 45.7%, and 27.6% of SLE, OC, and diabetes subjects, respectively, received all recommended services. Factors associated with a higher percentage of PPS received by SLE patients included older age (63.6% if age ≥65 years, 45.8% if age between 18 and 35 years), having medical insurance (61.1% for insured, 49.7% for uninsured), having a primary care physician (PCP) (59.0% if patient had PCP, 51.8% if patient did not have PCP), and being a non-smoker (61.9% for non-smokers, 49.9% for smokers).

CONCLUSIONS

Less than one-quarter of SLE patients from a southeast U.S. community received all the recommended services that were studied. Further research is warranted to unravel the barriers that prevent SLE patients from reaching appropriate standards of preventive care.

Recurrent acute coronary events in a young adult

Acute myocardial infarction (MI) in young adults is rare. Clinicopathological conditions such as nephrotic syndrome, antiphospholipid syndrome, spontaneous coronary artery spasms or embolism can be attributed to such events. In this case report, we present a 30-year-old male who had his first MI at the age of 20 years. He received percutaneous intervention as initial treatment. Despite aggressive risk factor management, he continued to have acute coronary events and was later diagnosed with antiphospholipid syndrome (APS). At the same time, he was diagnosed with severe chronic thromboembolic pulmonary hypertension and severe tricuspid regurgitation. He underwent pulmonary endartererectomy, tricuspid annuloplasty and radial artery bypass graft to the first obtuse marginal artery. Warfarin therapy was initiated upon the diagnosis of APS. Despite being therapeutic on warfarin and aggressive risk factor management, he had yet another MI. Coronary angiogram at this time showed fresh occlusion of the right coronary artery at the mid-segment, and the patient received two overlapping stents that achieved a good effect. This case emphasizes the importance of awareness, early recognition and aggressive management of patients with APS presenting chest pain or acute coronary events. Despite appropriate treatment, such as risk factor management and percutaneous interventions, recurrence of an acute coronary event is high. The presentation of younger patients with recurrent coronary events but no significant risk factors of atherosclerosis should evoke the suspicion of APS-related coronary artery disease, and all risk factors should be aggressively managed.

Longitudinal evolution of risk of coronary heart disease in systemic lupus erythematosus

OBJECTIVE

To produce evidence on the longitudinal evolution of risk factors for coronary heart disease (CHD) in patients with systemic lupus erythematosus (SLE).

METHODS

Based on data for 115 patients from the Montreal General Hospital Lupus Clinic (1971-2003) and for 4367 control subjects from the Framingham Offspring Study (1971-1994), we investigated the temporal evolution of total serum cholesterol, systolic blood pressure (SBP), body mass index (BMI), blood glucose, and estimated risk for CHD (reflecting the balance of changes in different risk factors). In analyses limited to patients with SLE, we assessed the effect of SLE duration on each risk factor, adjusting for age, calendar time, sex, baseline level of the risk factor, and medication use. Next, we assessed how the adjusted difference in the values of the risk factors between SLE and controls changes over time.

RESULTS

Among patients with SLE, longer disease duration was independently associated with higher SBP and blood glucose levels. Compared with controls, these patients appeared to have accelerated rates of increase in total cholesterol, blood glucose, and overall estimated CHD risk. The rate of increase in BMI was lower in patients with SLE than in controls.

CONCLUSION

Elevated CHD risk in patients with SLE appears to be at least partially mediated by accelerated increases in some CHD risk factors, longitudinal trajectories of which increasingly diverge over time from those of population controls.

Cardiovascular disease in systemic lupus erythematosus: the role of traditional and lupus related risk factors

Atherosclerosis is a chronic inflammatory disorder characterized by immune cell activation, inflammation driven plaque formation and subsequent destabilization. In other disorders of an inflammatory nature, the chronic inflammatory state per se has been linked to acceleration of the atherosclerotic process which is underlined by an increased incidence of cardiovascular disease (CVD) in disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and antiphopholipid (Hughes) syndrome (APS). SLE is an autoimmune disease that may affect any organ. Premature coronary heart disease has emerged as a major cause of morbidity and mortality in SLE. In addition to mortality, cardiovascular morbidity is also markedly increased in these patients, compared with the general population. The increased cardiovascular risk can be explained only partially by an increased prevalence of classical risk factors for cardiovascular disease; it also appears to be related to inflammation. Inflammation is increasingly being considered central to the pathogenesis of atherosclerosis and an important risk factor for vascular disease. Recent epidemiologic and pathogenesis studies have suggested a great deal in common between the pathogenesis of prototypic autoimmune disease such as SLE and that of atherosclerosis.

We will review traditional risk factors for CVD in SLE. We will also discuss the role of inflammation in atherosclerosis, as well as possible treatment strategies in these patients.

Periodontal disease as a risk factor for cardiovascular disease: suggestion of a further link in systemic lupus erythematosus

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Due to either infection or disease activity, elevated levels of inflammatory markers and up-regulation of the autoimmune process can contribute to the development of atherosclerosis in SLE patients. Periodontal diseases are among the most prevalent chronic infections in humans and are characterized by pathogen-induced oral inflammatory disease affecting the supporting tissues of teeth. Several cytokines capable of inducing systemic effects are produced during the course of this infection. The presence of these cytokines can be verified by changes in the levels of C-reactive protein (CRP). Periodontal disease is a well-known risk factor for atherosclerosis. The potential for beneficial prevention of CVD events through the use of periodontal treatment has been previously recommended. This review reinforces the hypothesis that periodontal infection could be a risk factor for CVD in patients diagnosed with SLE, and suggests that by reducing the progression of this oral infection, levels of inflammatory markers common to both diseases (SLE and periodontal disease) would likely decrease.

Aggressive cardiac involvement in systemic lupus erythematosus: a case report and a comprehensive literature review

Background. We present the case of a 35-year-old gentleman who presented with an aggressive cardiomyopathy with normal coronary arteries. He was later diagnosed with systemic lupus-related cardiomyopathy. Methods. We undertook an extensive review of the literature regarding cardiac manifestations of lupus and used over 100 journals to identify the key points in pathology, diagnosis, and treatment. Results. We have shown that cardiac lupus can be rapidly progressive and, unless treated early, can have severe consequences. The predominant pathologies are immune complex and accelerated atherosclerosis drive. Treatment comprised of high-level immunosuppression.

Comparative assessment of vascular function in autoimmune rheumatic diseases: considerations of prevention and treatment

Numerous autoimmune-inflammatory rheumatic diseases have been associated with accelerated atherosclerosis or other types of vasculopathy leading to increased cardio- and cerebrovascular disease risk. Traditional risk factors, as well as the role of systemic inflammation including cytokines, chemokines, proteases, autoantibodies, adhesion receptors and others have been implicated in the development of these vascular pathologies. The characteristics of vasculopathies may significantly differ depending on the underlying disease. While classical accelerated atherosclerosis has been associated with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or spondyloarthropathies (SpA), obliterative vasculopathy may rather be characteristic for systemic sclerosis (SSc) or mixed connective tissue disease (MCTD). Antiphospholipid antibodies have been implicated in vasculopathies underlying SLE, antiphospholipid syndrome (APS), RA and MCTD. There is also heterogeneity with respect to inflammatory risk factors. Cytokines, such as tumor necrosis factor-α (TNF-α) or interleukin 6 (IL-6) and immune complexes are primarily involved in arthritides, such as RA, SpA, as well as in SLE. On the other hand, autoantibodies including anti-oxLDL anti-cardiolipin and anti-β2GPI are rather involved in SLE- and APS-associated vasculopathies. Regarding the non-invasive assessment of vascular function, endothelial dysfunction, overt atherosclerosis and vascular stiffness may be indicated by brachial artery flow-mediated vasodilation (FMD), common carotid intima-media thickness (ccIMT) and aortic pulse-wave velocity (PWV), respectively. These abnormalities have been described in most inflammatory rheumatic diseases. While ccIMT and stiffness are relatively stable, FMD may be influenced by many confounding factors. In addition to traditional vasculoprotection, immunosuppressive agents including corticosteroids, traditional and biologic DMARDs may have significant vascular and metabolic effects. The official EULAR recommendations on the assessment and management of cardiovascular disease in arthritides have just been published, and similar recommendations in connective tissue diseases are to be developed soon.

Influence of atorvastatin on coronary calcifications and myocardial perfusion defects in systemic lupus erythematosus patients: a prospective, randomized, double-masked, placebo-controlled study

Introduction

Mortality in systemic lupus erythematosus (SLE) patients is influenced by an increased occurrence of severe cardiovascular complications. Statins have been proven to protect a wide spectrum of SLE patients from these complications. This study was conducted to determine the possible efficacy of atorvastatin in SLE patients as assessed by multi-detector computed tomography (MDCT)-based coronary calcium scoring and single photon emission computed tomography (SPECT) of the myocardium.

Methods

Sixty SLE patients in stable clinical conditions were randomized to receive either atorvastatin (40 mg daily; n = 28) or placebo (n = 32). Clinical and biochemical evaluation together with MDCT-based coronary calcium scoring and SPECT studies (Tc-99 m sestamibi) were performed at the time of randomization and after 1 year of treatment.

Results

At randomization, SPECT revealed perfusion defects at rest in 22 (36.7%) patients and exercise-induced defects in 8 (13.3%), whereas MDCT revealed coronary calcifications in 15 subjects (25%). Coronary calcium deposits increased after 1 year in the placebo group (plaque volume change from 35.2 ± 44.9 to 62.9 ± 72.4, P < 0.05; calcium score from 32.1 ± 39.1 to 59.5 ± 64.4; P < 0.05), but not in the atorvastatin group (plaque volume 54.5 ± 62.4 vs. 51.0 ± 47.6, P not significant; calcium score 44.8 ± 50.6 vs. 54.9 ± 62.5, P not significant). The atorvastatin group showed a decrease in total serum cholesterol (from 5.1 ± 1.2 to 4.4 ± 0.7 mmol/L, P < 0.05), LDL cholesterol (2.9 ± 1.0 to 2.3 ± 0.6 mmol/L, P < 0.05), triglycerides (1.6 ± 0.6 to 1.2 ± 0.5 mmol/L, P < 0.05), and C-reactive protein (CRP) (4.4 ± 4.1 to 2.7 ± 1.7 mg/L, P < 0.05). There was no change in the mean Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score in patients from both groups. Perfusion defects observed at randomization showed no change after one year treatment with atorvastatin.

Conclusions

In SLE patients 40 mg of atorvastatin daily for 1 year led to a decrease in serum lipids and CRP levels. Additionally the progression of atherosclerosis, as assessed by MDCT-based coronary calcium scoring, is restrained by atorvastatin treatment. The value of statin treatment in patients with SLE free from cardiovascular disease clinical symptoms should be addressed in large, prospective clinical trials.

The endothelium: an interface between autoimmunity and atherosclerosis in systemic lupus erythematosus?

Patients with systemic lupus erythematosus (SLE) have an increased risk of developing cardiovascular disease (CVD). Traditional risk factors fail to fully explain all of this increased risk. As atherosclerosis is recognized as a chronic inflammatory disease, it has been advocated that persistent inflammatory activity in patients with SLE is the principal mechanism that promotes accelerated atherogenesis. Autoantibodies in SLE might contribute to the pathogenesis of atherosclerosis by causing injury to the endothelium and altering the metabolism of lipoproteins involved in atherogenesis. Circulating immune complexes and anti-endothelial cell antibodies can induce expression of a proinflammatory and proadhesive endothelial cell phenotype. Similarly, antiphospholipid antibodies (aPL) may directly activate the endothelium or, via cross-reactivity with other antigens, interfere with lipoprotein metabolism. Antibodies to oxidized low-density lipoprotein (anti-oxLDL) rise with anti-double-stranded DNA antibody titres, complement activation and disease activity scores in patients with SLE. Both clinical and in vitro studies, however, have yielded conflicting results regarding the role of anti-oxLDL and aPL antibodies in CVD. Elevated levels of antibodies to high-density lipoprotein (HDL) and apolipoprotein A1 (the principal protein fraction of HDL) are found in patients with coronary ischaemia. Titres of these antibodies are significantly higher in SLE patients with persistent inflammatory disease and correlate inversely with activity of paraoxonase, a key enzyme that gives HDL its anti-oxidant properties. This review summarizes the evidence that autoantibodies in SLE might contribute to the pathogenesis of atherosclerosis by causing injury to the endothelium and altering the metabolism of lipoproteins involved in atherogenesis.

Osteoporosis and cardiovascular disease care in systemic lupus erythematosus according to new quality indicators

OBJECTIVES

Quality indicators (QIs) for the assessment of care of patients with systemic lupus erythematosus (SLE) have been proposed. We evaluated care according to these proposed QIs for osteoporosis and cardiovascular disease (CVD) in patients with SLE in our rheumatology practice.

METHODS

We selected 200 patients with SLE according to American College of Rheumatology Criteria and ≥2 visits to our practice in 2007 to 2008. We performed a structured medical record review and collected demographics, SLE and past medical history, medications, laboratories and data concerning osteoporosis, and CVD management. We employed univariable analyses and multivariable regression analyses to test for factors associated with care meeting the proposed QIs.

RESULTS

Ninety-four percent of patients were female and 64% were white. Mean age was 46.3 years and mean lupus duration was 15.3 years. Twenty-nine percent were taking ≥7.5 mg prednisone per day for ≥3 months. The proportions of patients for whom care met the proposed QIs were as follows: 59% for bone mineral density testing, 62% for calcium and vitamin D supplementation, and 86% for antiresorptive or anabolic osteoporosis medications. Only 3% had 5 cardiac risk factors assessed within the year and 26% had 4 cardiac risk factors assessed annually. Smoking, fasting lipid panels, and diabetes mellitus were rarely assessed annually. Having a primary care physician within our health care network increased care meeting QIs.

CONCLUSIONS

Care according to newly proposed QIs for osteoporosis and CVD was suboptimal in our academic center. To standardize and improve care of patients with SLE, we suggest specific changes to the proposed QIs.

Use of a strategy based on calculated risk scores in managing cardiovascular risk factors in a large British cohort of patients with systemic lupus erythematosus

OBJECTIVE

To develop a strategy for stratifying risk of cardiovascular disease (CVD) in a cohort of patients with SLE and to test the usefulness of this strategy in rationalizing management of cardiovascular risk factors.

METHODS

For each patient, data were collected once each year to allow calculation of risk of developing CVD in the next 10 years. Those with risk values >7.5% were considered for intervention to reduce risk. The risk figures and effect of this strategy on management of the cohort as a whole were assessed after 3 years. Patients who had been identified as smokers in 2005 were contacted in 2008 to assess changes in their smoking behaviour.

RESULTS

Over 3 years, 308 patients (>90%) of the cohort had CVD risk assessed at least once. Although 10-year CVD risk exceeded 7.5% in 35 patients, the majority (24) of these had either diabetes mellitus or previous CVD for which established cardiovascular risk reduction protocols already exist. Calculation of risk scores did not alter management in 96.5% of the patients. Ninety percent of the smokers remembered being counselled about smoking in the lupus clinic, 70% had received help to reduce smoking and 47% had either reduced or stopped.

CONCLUSION

A protocol mandating regular assessment of cardiovascular risk factors in our lupus clinic resulted in this issue being discussed with >90% of the patients and there was some evidence of an impact on smoking. However, use of these factors to calculate 10-year risk scores did not alter management in over 96% of the cases.

A pravastatin dose-escalation study in systemic lupus erythematosus

Statin medications have been suggested for widespread use in patients with systemic lupus erythematosus (SLE). We studied the dose effectiveness and tolerability of pravastatin in SLE. We compared 41 SLE subjects in a two-month open-label dose-titration study of pravastatin to 22 SLE controls. Lipids, ALT, CPK, CRP, adverse effects were assessed. Linear mixed models assessed changes in lipids and CRP, comparing pravastatin subjects to controls. After 1 month of pravastatin 10 mg a day, total cholesterol decreased by 16% (+/-12.1%) and LDL by 24% (+/-17%), compared with 1.8% (+/-7.5%) and 2.6% (+/-8.6%) decreases in controls (P < 0.001). CRP did not decline. Glucocorticoids appeared to decrease pravastatin effectiveness. Serum CPK increased in one subject. Pravastatin reduced LDL and total cholesterol levels approximately the same degree observed in normal individuals, but the effect appeared blunted in those on modest doses of glucocorticoids and those with higher BMI.

Factors determining participation in prevention trials among systemic lupus erythematosus patients: a qualitative study

OBJECTIVE

A feasibility study for a trial of strategies for the prevention of atherosclerosis in patients with systemic lupus erythematosus (SLE) was stopped because of inadequate recruitment. There is little understanding of the factors influencing patients' decisions about participation in prevention trials. Our goal was to determine factors that patients with SLE consider in deciding about participating in prevention trials, to uncover concerns about SLE trials, and to investigate how study design and purpose affect participation decisions.

METHODS

We conducted focus groups with trial participants (n = 13), trial nonparticipants (n = 8), and a group of patients with diabetes (n = 9). We conducted telephone interviews with SLE patients who refused participation in the trial and the focus groups (n = 10). A trained facilitator elicited factors influencing participation decisions. Transcripts were coded and grouped into themes using grounded theory.

RESULTS

Demographic characteristics of the groups were similar. Seven factors emerged as important in decision making: current health status, study design, physician involvement, personal benefit, altruism, time, and incentives. These factors were considered by individuals who elected to participate and those who did not, but weighed differently. Among the trial participants, good health status, encouragement from one's physician, and desires to learn and to contribute stimulated participation. Reasons for nonparticipation included current health status, medication and randomization concerns, and personal factors.

CONCLUSION

We observed that similar factors were weighed differently by participants and nonparticipants. Our results suggest that strategies such as health education, enlistment of personal physicians, and limitation of time requirements may enhance recruitment of patients with SLE into clinical prevention trials.

B-type natriuretic peptide (BNP) levels in female systemic lupus erythematosus patients: what is the clinical significance?

Cardiovascular disease is a major cause of death in patients with systemic lupus erythematosus (SLE) especially during the late phase of the disease. This study was conducted to evaluate B-type natriuretic peptide (BNP) levels in female SLE patients without cardiac symptoms and to investigate whether BNP levels correlated with echocardiographic findings. We studied 59 women with SLE and 33 healthy women. SLE patients with history of cardiac disease, diabetes mellitus, hypertension, and other inflammatory diseases were excluded from the study. All subjects had a complete history and physical examination. Overall disease activity assessment in SLE patients at the time of the study were derived by calculation of SLE disease activity index (SLEDAI). BNP levels were determined, and transthoracic echocardiography were performed in all subjects. There was no difference between SLE patients and controls in terms of age, blood pressure, smoking status, plasma glucose, creatinine levels, and lipid profiles. Nine patients had SLEDAI score greater than 5. All subjects had an EF greater than 55%. Diastolic dysfunction was more frequent in lupus patients than in controls (15 [25.4%] vs. 2 [6%]; p = 0.022). BNP levels of SLE patients were significantly higher than controls (median 17.9 range [5-211] pg/ml vs. median 14.7 range [5-39.7] pg/ml; p = 0.033). Twenty-seven of the SLE patients (46%) and seven of the controls (21%) had BNP levels greater than or equal to 20 pg/ml (p = 0.019). There were no differences in BNP levels of SLE patients with and without diastolic dysfunction (median 17.8 range [5-117] pg/ml vs. median 18.5 range [5-211] pg/mL; p = NS). BNP levels were positively correlated with left atrium diameter (r (2) = 0.39, p = 0.001). BNP levels did not correlate with erythrocyte sedimentation rate/C-reactive protein levels, SLEDAI scores, total steroid dosage used, or other echocardigraphic parameters. BNP levels were increased in female SLE patients without cardiac symptoms as compared to healthy controls. Although none of the SLE patients in our study had clinical signs of ischemic heart disease, increased levels of BNP in SLE patients might be a reflection of a ischemic myocardial tissue.

Heart involvement in systemic lupus erythematosus, anti-phospholipid syndrome and neonatal lupus

Cardiac involvement is one of the main complications substantially contributing to the morbidity and mortality of patients suffering from systemic autoimmune diseases. All the anatomical heart structures can be affected, and multiple pathogenic mechanisms have been reported. Non-organ-specific autoantibodies have been implicated in immune complex formation and deposition as the initial triggers for inflammatory processes responsible for Libman-Sacks verrucous endocarditis, myocarditis and pericarditis. Anti-phospholipid antibodies have been associated with thrombotic events in coronary arteries, heart valve involvement and intra-myocardial vasculopathy in the context of primary and secondary anti-phospholipid syndrome. Antibodies-SSA/Ro and anti-SSB/La antigens play a major pathogenic role in affecting the heart conduction tissue leading to the electrocardiographic abnormalities of the neonatal lupus syndrome and have been closely associated with endocardial fibroelastosis.

Atherosclerosis and systemic lupus erythematosus

Large increases in mortality related to premature atherosclerosis with coronary artery disease have been reported in patients with systemic lupus erythematosus (SLE). The current pathogenic hypothesis for atherosclerosis involves not only the classic factors identified in the Framingham study, but also includes chronic inflammation, corticosteroid therapy, excess of traditional risk factors, autoantibodies, immune complexes (containing antibodies to phospholipids, to oxidized low-density lipoproteins, and to endothelial cells), and cytokine-producing activated T cells. Early risk factor intervention and effective control of inflammation should be incorporated into the management of SLE to protect against atherosclerosis.

Clinical manifestations and pathogenesis of hydroxyapatite crystal deposition in juvenile dermatomyositis

Pathologic deposition of mineral in the form of bone-like hydroxyapatite is a frequent occurrence in juvenile dermatomyositis (JDM) and other connective tissue diseases. Although the sizes of the mineral crystals in JDM are similar to those in bone, there is much more mineral in the deposits than there is in bone. Bone matrix proteins also accumulate associated with the deposits. The reasons for the formation of these deposits are not known. It is our hypothesis that persistent inflammation is a component of JDM and other hydroxyapatite deposition diseases. Other contributing factors are genetic, environmental, and physical chemical. This paper discusses the influence of inflammation on the deposition of hydroxyapatite, with emphasis on the clinical and environmental factors that may facilitate the formation of calcific deposits in JDM.

Lipid metabolism, atherogenesis and CD1-restricted antigen presentation

CD1 molecules are a family of major histocompatibility complex (MHC)-related glycoproteins that present lipid and glycolipid antigens to T cells. Interestingly, it has been demonstrated that CD1d-restricted T cells have a pathogenic role in atherosclerosis. Recent studies suggest an association between the cellular machinery that loads CD1 molecules with glycolipids and several key proteins in lipid metabolism. These proteins include the sphingolipid activator proteins (SAPs), microsomal triglyceride transfer protein (MTP) and apolipoprotein E (apoE). MTP and SAPs seem to be crucial for loading CD1d with lipids in the endoplasmic reticulum and endosomal compartments, respectively, whereas apoE facilitates efficient uptake and delivery of exogenous lipid antigens to CD1d in endosomal compartments. These studies reveal new and unexpected relationships between lipid metabolism and antigen presentation by CD1 molecules. Targeting this pathway of immune activation might have therapeutic potential for the treatment of chronic inflammatory diseases.

Glucocorticoid receptor regulates ATP-binding cassette transporter-A1 expression and apolipoprotein-mediated cholesterol efflux from macrophages

OBJECTIVE

The ATP-binding cassette transporter-A1 (ABCA1) regulates cholesterol efflux from cells and is involved in high-density lipoprotein metabolism and atherogenesis. The objective of this study was to investigate the effect of dexamethasone (Dex) and other glucocorticoid receptor (GR) ligands on apolipoprotein AI-mediated cholesterol efflux from macrophages and ABCA1 expression in them.

METHODS AND RESULTS

Dex, a GR agonist, decreased ABCA1 mRNA levels in a dose- and time-dependent fashion, and RU486, a GR antagonist, reversed the inhibitory effect of Dex. The effects of Dex and RU486 on ABCA1 protein levels and apolipoprotein AI-mediated cholesterol efflux from the macrophages were consistent with these changes in mRNA levels. Transfected RAW264.7, together with a human ABCA1 promoter-luciferase construct, inhibited transcriptional activity by Dex and overexpression of human GR. Transrepression by GR was not mediated by liver X receptor (LXR), because there were no differences in the effects of the GR ligands on promoter activity between a reporter construct with mutations at the LXR binding site and one without the mutations, and no changes were brought about in ABCG1 and ABCG4 expression by GR ligands.

CONCLUSIONS

Our results showed that GR ligands affected ABCA1 expression and cholesterol efflux from macrophages, which are regulated by GR through a LXR-independent mechanism.

Bone mineral density in postmenopausal Chinese patients with systemic lupus erythematosus

The objective was to study the bone mineral density (BMD) and its clinical determinants in a cohort of postmenopausal patients with systemic lupus erythematosus (SLE). All postmenopausal SLE patients receiving long term glucocorticoids were identified from our medical clinics. Lumbar and femoral BMDs were measured by dual X-ray absorptiometry. Clinical determinants of BMD were studied by simple and multiple linear regression. Variables evaluated were: age, body mass index, parity, duration of menopause, smoking and alcohol drinking, duration of SLE and steroid treatment, cumulative prednisone dose, clinical and serological profile, disease activity, damage index and the use of medications. In total, 34 patients were studied. The mean age was 52.9+/-4.9 years and the median duration of SLE was 75.5 months. The mean duration of menopause was 5.2+/-3.9 years and the daily maintenance dose of prednisone was 4.0+/-2.5 mg/day. At the lumbar spine, 33% of the patients were osteopenic and 48% were osteoporotic. Two patients had thoracic and lumbar vertebral compression fractures. At the nondominant femoral neck, 74% of patients were osteopenic but only 3% was osteoporotic. In a multivariate model, the current or past use of hydroxychloroquine (HCQ) was associated with a higher spinal BMD. The presence of anti-Sm and the absence of anti-Ro were associated with a higher femoral BMD. It was concluded that osteoporosis, especially at the spine, is a common and serious problem in postmenopausal Chinese SLE patients receiving long term glucocorticoid therapy. Active intervention should be considered. The protective role of HCQ has to be confirmed with further studies.

Cardiac risk factor awareness and management in patients with systemic lupus erythematosus

OBJECTIVE

To assess awareness and management of traditional cardiac risk factors (CRFs) in patients with systemic lupus erythematosus (SLE) and physicians.

METHODS

SLE patients (n=110) completed a questionnaire concerning CRFs. Medical records were reviewed blinded to questionnaire results for the presence and management of 6 CRFs: hypertension, hypercholesterolemia, smoking, obesity, diabetes mellitus, and physical inactivity.

RESULTS

Subjects were predominantly female (97%), mean (+/-SD) age was 43.4 years (+/-11.8), mean SLE duration was 15.3 years (+/-7.2), and 51% had > or =2 CRFs by self report. Twenty-three percent had never had their cholesterol levels checked. Hypercholesterolemia was more frequently documented in the medical records than reported by the patient (33% versus 24%). Physical inactivity was more frequently self reported than documented (59% versus 23%). Rheumatologists and patients had low interrater reliability for the presence of hypercholesterolemia (kappa=0.26) and physical inactivity (kappa=-0.02). More than half (58%) of CRFs were treated, and 21% of subjects with elevated cholesterol received a medication.

CONCLUSION

Recognition, recording, and management of CRFs falls short given the significance of the problem.

Barriers to a trial of atherosclerosis prevention in systemic lupus erythematosus

OBJECTIVE

The effectiveness of aggressive management of traditional risk factors for accelerated atherosclerosis in systemic lupus erythematosus (SLE) has been advocated but not proven. We conducted a pilot, randomized, controlled trial of known prevention medications (pravastatin, ramipril, aspirin, and a combination B vitamin) plus individualized cardiovascular prevention education. We describe our experience in recruiting and retaining patients with SLE in this trial.

METHODS

Patients with SLE by American College of Rheumatology criteria who lived within 1 hour of the hospital and had visits within the past 3 years were screened. All eligible patients were contacted by the principal investigator who was not their physician. The reasons for nonparticipation were elicited in a nonjudgmental manner.

RESULTS

A total of 662 patients met the selection criteria for the study. Of these, 295 patients (45%) with contraindications to study medications were excluded. Ninety-seven (40%) of 244 eligible patients refused to participate. More than 40% of those phoned were unwilling to participate and, among those, 19% felt they were too sick, too well, or taking too many medications already. A total of 41 patients were enrolled in the trial, and 22 dropped out within 4 months.

CONCLUSION

SLE is a chronic disease, and the development and testing of interventions aimed at the prevention of long-term sequelae are of paramount importance. Prevention trials in SLE face serious challenges, including the recruitment and retention of participants. Our experience provides insights into the barriers to participation in randomized prevention trials in SLE.

Dyslipoproteinemia and premature atherosclerosis in pediatric systemic lupus erythematosus

While modern treatments for systemic lupus erythematosus (SLE) have resulted in greatly improved long term outcome in children and adults, complications of atherosclerosis have become a major cause of morbidity and mortality. Although children and adolescents with SLE rarely experience adverse cardiovascular events before adulthood, dyslipoproteinemia and early evidence of premature atherosclerosis is present much earlier. Accelerated atherogenesis in SLE is multifactorial, most likely reflecting vascular, immune, and inflammatory changes along with medication effects. The long term complications of cardiovascular disease in childhood lupus present a particularly important target for intervention because of the potential return on investment by significantly lengthening life and improving quality of life over many decades. An ongoing multi-center, randomized, controlled trial, Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE), testing the efficacy of statins in preventing premature atherosclerosis in children and adolescents with SLE will guide future therapeutic intervention.

Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature

BACKGROUND

Hydroxychloroquine (HCQ) is extensively used in the long-term treatment of systemic lupus erythematosus (SLE). Although considered by clinicians to be relatively safe, serious side effects have been documented in the literature. Retinotoxicity has received the most attention, whereas neuromyotoxicity and cardiotoxicity have been described in isolated case reports. We present 2 cases of potential cardiotoxicity occurring in patients with SLE while receiving long-term HCQ therapy.

OBJECTIVE

To review the incidence, presentation, and mechanism of serious antimalarial toxicity, and to discuss the impact of HCQ on cardiac health in SLE.

METHODS

The authors reviewed the English-language literature from 1948 to December 2002 using Medline databases.

RESULTS

In addition to our patients, there are 2 published cases of biopsy-proven HCQ cardiotoxicity in the English-language literature. Both occurred in patients with SLE. The literature indicates that antimalarial cardiotoxicity may be of particular importance in patients with SLE given their already increased cardiac risk due to primary heart disease and accelerated atherosclerosis. Endomyocardial biopsy reveals a constellation of findings including vacuolar myopathy, myeloid bodies, and curvilinear bodies.

CONCLUSIONS

As HCQ use among SLE patients increases, clinicians should be alert to the possibility of antimalarial cardiotoxicity. The potential severity and reversibility of this complication underscore the importance of timely diagnosis. The cases presented here, one with biopsy and one without, illustrate the utility of endomyocardial biopsy in HCQ-treated SLE patients with cardiac complaints to ensure accurate diagnosis and appropriate management.

Systemic lupus erythematosus. How to manage, when to refer

Systemic lupus erythematosus (SLE) is an autoimmune disease seen predominately in women between the ages of 20 and 40. Because the disease varies in severity and can affect major organ systems, patients should be monitored carefully for organ damage and medication toxicity. In this article, Drs Dall'Era and Davis review the diagnosis of SLE as well as its epidemiologic factors and clinical characteristics. The section on therapy constitutes a practical resource for primary care physicians who care for patients with SLE.

Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus

BACKGROUND

Although systemic lupus erythematosus is associated with premature myocardial infarction, the prevalence of underlying atherosclerosis and its relation to traditional risk factors for cardiovascular disease and lupus-related factors have not been examined in a case-control study.

METHODS

In 197 patients with lupus and 197 matched controls, we performed carotid ultrasonography, echocardiography, and an assessment for risk factors for cardiovascular disease. The patients were also evaluated with respect to their clinical and serologic features, inflammatory mediators, and disease treatment.

RESULTS

The risk factors for cardiovascular disease were similar among patients and controls. Atherosclerosis (carotid plaque) was more prevalent among patients than the controls (37.1 percent vs. 15.2 percent, P<0.001). In multivariate analysis, only older age, the presence of systemic lupus erythematosus (odds ratio, 4.8; 95 percent confidence interval, 2.6 to 8.7), and a higher serum cholesterol level were independently related to the presence of plaque. As compared with patients without plaque, patients with plaque were older, had a longer duration of disease and more disease-related damage, and were less likely to have multiple autoantibodies or to have been treated with prednisone, cyclophosphamide, or hydroxychloroquine. In multivariate analyses including patients with lupus, independent predictors of plaque were a longer duration of disease, a higher damage-index score, a lower incidence of the use of cyclophosphamide, and the absence of anti-Smith antibodies.

CONCLUSIONS

Atherosclerosis occurs prematurely in patients with systemic lupus erythematosus and is independent of traditional risk factors for cardiovascular disease. The clinical profile of patients with lupus and atherosclerosis suggests a role for disease-related factors in atherogenesis and underscores the need for trials of more focused and effective antiinflammatory therapy.

SLE - Practical and theoretical barriers to the prevention of accelerated atherosclerosis in systemic lupus erythematosus

Accelerated atherosclerotic vascular disease (ASVD) is a major cause of death in systemic lupus erythematosus (SLE). Although many authorities are calling for aggressive assessment and management of cardiac risk factors in patients with SLE, both theoretical and practical barriers to this approach exist. It seems that SLE and/or its treatment are themselves strong risk factors for the development of ASVD and it is unclear how much this risk can be decreased by the control of traditional risk factors. Studies from several centers have shown that suboptimal risk factor management and barriers to acceptance of these measures must also be studied further.

Current concepts for the management of systemic lupus erythematosus in adults: a therapeutic challenge

Systemic lupus erythematosus (SLE) is a chronic, autoimmune rheumatic disease with many clinical presentations typically affecting women of childbearing age. The successful therapy of SLE depends upon treating both symptoms and the underlying inflammation. Both non-pharmacological as well as pharmacological therapies are invariably required. Non-pharmacological therapy includes avoiding over-exposure to sunlight with the use of adequate sunscreen protection, avoiding "live" vaccination if on immunosuppressive agents, adherence to a diet low in saturated fat and high in fish oil, stress avoidance, and smoking cessation. Pharmacological measures revolve around four main classes of drugs: non-steroidal anti-inflammatory drugs, antimalarials, corticosteroids, and cytotoxic agents. Cyclophosphamide and azathioprine are the two most commonly used cytotoxic agents and these in combination with corticosteroids need to be employed early if there is major organ involvement to prevent or minimise irreversible damage. The potential side effects of corticosteroids and cytotoxic agents need constant consideration. The rapid developments in biotechnology of recent years may soon lead to new and more specific therapies for patients with SLE.