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Katsumata Y, Inoue E, Harigai M, Cho J, Louthrenoo W, Hoi A, Golder V, Lau CS, Lateef A, Chen YH, Luo SF, Wu YJJ, Hamijoyo L, Li Z, Sockalingam S, Navarra S, Zamora L, Hao Y, Zhang Z, Chan M, Oon S, Ng K, Kikuchi J, Takeuchi T, Goldblatt F, O'Neill S, Tugnet N, Law AHN, Bae SC, Tanaka Y, Ohkubo N, Kumar S, Kandane-Rathnayake R, Nikpour M, Morand EF. Risk of flare and damage accrual after tapering glucocorticoids in modified serologically active clinically quiescent patients with systemic lupus erythematosus: a multinational observational cohort study. Ann Rheum Dis 2024; 83:998-1005. [PMID: 38423757 DOI: 10.1136/ard-2023-225369] [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: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES To assess the risk of flare and damage accrual after tapering glucocorticoids (GCs) in modified serologically active clinically quiescent (mSACQ) patients with systemic lupus erythematosus (SLE). METHODS Data from a 12-country longitudinal SLE cohort, collected prospectively between 2013 and 2020, were analysed. SLE patients with mSACQ defined as the state with serological activity (increased anti-dsDNA and/or hypocomplementemia) but without clinical activity, treated with ≤7.5 mg/day of prednisolone-equivalent GCs and not-considering duration, were studied. The risk of subsequent flare or damage accrual per 1 mg decrease of prednisolone was assessed using Cox proportional hazard models while adjusting for confounders. Observation periods were 2 years and censored if each event occurred. RESULTS Data from 1850 mSACQ patients were analysed: 742, 271 and 180 patients experienced overall flare, severe flare and damage accrual, respectively. Tapering GCs by 1 mg/day of prednisolone was not associated with increased risk of overall or severe flare: adjusted HRs 1.02 (95% CI, 0.99 to 1.05) and 0.98 (95% CI, 0.96 to 1.004), respectively. Antimalarial use was associated with decreased flare risk. Tapering GCs was associated with decreased risk of damage accrual (adjusted HR 0.96, 95% CI, 0.93 to 0.99) in the patients whose initial prednisolone dosages were >5 mg/day. CONCLUSIONS In mSACQ patients, tapering GCs was not associated with increased flare risk. Antimalarial use was associated with decreased flare risk. Tapering GCs protected mSACQ patients treated with >5 mg/day of prednisolone against damage accrual. These findings suggest that cautious GC tapering is feasible and can reduce GC use in mSACQ patients.
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Affiliation(s)
- Yasuhiro Katsumata
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eisuke Inoue
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Jiacai Cho
- National University Hospital of Singapore, Singapore
| | | | - Alberta Hoi
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | | | | | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shue-Fen Luo
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Kuei Shan, Taiwan
| | - Yeong-Jian Jan Wu
- Department of Medicine, Division of Allergy, Immunology and Rheumatology, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Laniyati Hamijoyo
- Rheumatology Division, Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Sargunan Sockalingam
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Sandra Navarra
- University of Santo Tomas Hospital, Manila, The Philippines
| | - Leonid Zamora
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, The Philippines
| | - Yanjie Hao
- University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Zhuoli Zhang
- Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | | | - Shereen Oon
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Kristine Ng
- Waitemata District Health Board, Auckland, New Zealand
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University, Saitama, Japan
| | - Fiona Goldblatt
- Repatriation General Hospital, Daw Park, South Australia, Australia
| | - Sean O'Neill
- University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | | | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea (the Republic of)
- Hanyang University Institute for Rheumatology Research, Seoul, Korea (the Republic of)
- Hanyang Institute of Bioscience and Biotechnology, Seoul, Korea (the Republic of)
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Naoaki Ohkubo
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Mandana Nikpour
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
- The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Ding Y, Zhou Y, Zhan F, Xu J, Duan X, Luo H, Zhao C, Yang M, Wu R, Wu L, Chen Z, Wei W, Huang C, Wu C, Zhang S, Jiang N, Xu D, Leng X, Wang Q, Tian X, Li M, Zeng X, Zhao J. Phenotypic subgroup in serologically active clinically quiescent systemic lupus erythematosus: A cluster analysis based on CSTAR cohort. MED 2024:S2666-6340(24)00251-4. [PMID: 38991598 DOI: 10.1016/j.medj.2024.06.005] [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: 03/08/2024] [Revised: 04/03/2024] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Serologically active clinically quiescent (SACQ) is a state within systemic lupus erythematosus (SLE) characterized by elevated serologic markers without clinical activity. The heterogeneity in SACQ patients poses challenges in disease management. This multicenter prospective study aimed to identify distinct SACQ subgroups and assess their utility in predicting organ damage. METHODS SACQ was defined as a sustained period of at least 6 months with persistent serologic activity, marked by positive anti-double-stranded DNA (dsDNA) antibodies and/or hypocomplementemia, and without clinical activity. Cluster analysis was employed, utilizing 16 independent components to delineate phenotypes. FINDINGS Among the 4,107 patients with SLE, 990 (24.1%) achieved SACQ within 2.0 ± 2.3 years on average. Over a total follow-up of 7,105.1 patient years, 340 (34.3%) experienced flares, and 134 (13.5%) developed organ damage. Three distinct SACQ subgroups were identified. Cluster 1 (n = 219, 22.1%) consisted predominantly of elderly males with a history of major organ involvement at SLE diagnosis, showing the highest risk of severe flares (16.4%) and organ damage (27.9%). Cluster 2 (n = 279, 28.2%) was characterized by milder disease and a lower risk of damage accrual (5.7%). Notably, 86 patients (30.8%) in cluster 2 successfully discontinued low-dose glucocorticoids, with 49 of them doing so without experiencing flares. Cluster 3 (n = 492, 49.7%) featured the highest proportion of lupus nephritis and a moderate risk of organ damage (11.8%), with male patients showing significantly higher risk of damage (hazard ratio [HR] = 4.51, 95% confidence interval [CI], 1.82-11.79). CONCLUSION This study identified three distinct SACQ clusters, each with specific prognostic implications. This classification could enhance personalized management for SACQ patients. FUNDING This work was funded by the National Key R&D Program (2021YFC2501300), the Beijing Municipal Science & Technology Commission (Z201100005520023), the CAMS Innovation Fund (2021-I2M-1-005), and National High-Level Hospital Clinical Research Funding (2022-PUMCH-D-009).
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Affiliation(s)
- Yufang Ding
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Feng Zhan
- Department of Rheumatology and Immunology, Hainan General Hospital, Haikou 570311, China
| | - Jian Xu
- Department of Rheumatology and Immunology, First Affiliated Hospital of Kunming Medical University, Kunming 650032, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Hui Luo
- Department of Rheumatology and Immunology, Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Cheng Zhao
- Department of Rheumatology and Immunology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, China
| | - Min Yang
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Rui Wu
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, China
| | - Zhen Chen
- Department of Rheumatology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, China
| | - Wei Wei
- Department of Rheumatology and Immunology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Can Huang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chanyuan Wu
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Nan Jiang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaomei Leng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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Nikolopoulos D, Fotis L, Gioti O, Fanouriakis A. Tailored treatment strategies and future directions in systemic lupus erythematosus. Rheumatol Int 2022; 42:1307-1319. [PMID: 35449237 DOI: 10.1007/s00296-022-05133-0] [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: 03/07/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
Abstract
Systemic lupus erythematosus (SLE) represents a diagnostic and therapeutic challenge for physicians due to its protean manifestations and unpredictable course. The disease may manifest as multisystemic or organ-dominant and severity at presentation may vary according to age at onset (childhood-, adult- or late-onset SLE). Different manifestations may respond variably to different immunosuppressive medications and, even within the same organ-system, the severity of inflammation may vary from mild to organ-threatening. Current "state-of-the-art" in SLE treatment aims at remission or low disease activity in all organ systems. Apart from hydroxychloroquine and glucocorticoids (which should be used with caution), the choice of the appropriate immunosuppressive agent should be individualized and depend on the prevailing manifestation, severity stratification and patient childbearing potential. In this review, we provide an overview of therapeutic options for the various organ manifestations and severity patterns of the disease, different phenotypes (such as multisystem versus organ-dominant disease), as well as specific considerations, including lupus with antiphospholipid antibodies, childhood and late-onset disease, as well as treatment options during pregnancy and lactation.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.
| | - Lampros Fotis
- Department of Pediatrics, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece
| | - Ourania Gioti
- Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology, 4th Department of Internal Medicine, "Attikon" University Hospital, Medical School National and Kapodistrian University of Athens, Athens, Greece.,1st Department of Propaedeutic Internal Medicine, "Laikon" General Hospital, Medical School National Kapodistrian University of Athens, Athens, Greece
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