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Touma Z, Kayaniyil S, Parackal A, Bonilla D, Su J, Qian C, Miller SD, Johnston A, Gahn J, Hille ED, Ohsfeldt R, Chandran S. Unfavorable Outcomes Associated With Glucocorticoid Use in Current Standard-of-Care Management of Systemic Lupus Erythematosus in Canada. ACR Open Rheumatol 2024. [PMID: 38924684 DOI: 10.1002/acr2.11680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/06/2024] [Accepted: 04/26/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE Our objective was to describe the administration of glucocorticoids (GCs) and characterize its association with organ damage in a longitudinal systemic lupus erythematosus (SLE) cohort over a time period spanning the introduction of biologics in Canada. METHODS A retrospective observational study was conducted using data from a large SLE cohort in Canada, including adults without lupus nephritis or central nervous system lupus. Patients were observed from time of entry into the cohort to the last available clinic visit (up to December 31, 2020), with a minimum of 24 months of follow-up. Demographic and clinical characteristics, including average disease activity, treatment administration, and prevalence of organ damage, were examined. Organ damage was stratified by GC administration. RESULTS A total of 1,255 patients were included. The mean follow-up duration was 10.5 (SD 8.6) years. One hundred eighty-two (15%) patients had organ damage at baseline. More than 80% of patients were prescribed GCs over the follow-up period, almost all patients had long-term GC treatment, and only 5% of patients took any biologics. Organ damage was more frequent in patients with a higher average GC dose and greater years of GC exposure. CONCLUSION In this large cohort of patients with SLE, the majority of patients continue to rely on GC for SLE symptom management, with limited administration of biologics. GC administration was correlated with increased irreversible organ damage. Access to novel GC-sparing treatment options is critical to improve long-term outcomes for patients with SLE, especially given the continued reliance on GC despite the introduction of biologics.
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Affiliation(s)
- Zahi Touma
- Toronto Western Hospital, Toronto, Ontario, Canada
| | | | | | | | - Jiandong Su
- Toronto Western Hospital, Toronto, Ontario, Canada
| | - Christina Qian
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Sally D Miller
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Adam Johnston
- Medical Decision Modeling Inc., Indianapolis, Indiana
| | - James Gahn
- Medical Decision Modeling Inc., Indianapolis, Indiana
| | - Erik D Hille
- Medical Decision Modeling Inc., Indianapolis, Indiana
| | - Robert Ohsfeldt
- Medical Decision Modeling Inc., Indianapolis, Indiana, and Texas A&M School of Public Health, College Station
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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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3
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Almeida-Brasil CC, Hanly JG, Urowitz M, Clarke AE, Ruiz-Irastorza G, Gordon C, Ramsey-Goldman R, Petri M, Ginzler EM, Wallace DJ, Bae SC, Romero-Diaz J, Dooley MA, Peschken C, Isenberg D, Rahman A, Manzi S, Jacobsen S, Lim S, van Vollenhoven RF, Nived O, Jönsen A, Kamen DL, Aranow C, Sanchez-Guerrero J, Gladman DD, Fortin PR, Alarcón GS, Merrill JT, Kalunian K, Ramos-Casals M, Steinsson K, Zoma A, Askanase A, Khamashta MA, Bruce IN, Inanc M, Abrahamowicz M, Bernatsky S. Flares after hydroxychloroquine reduction or discontinuation: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2022; 81:370-378. [PMID: 34911705 PMCID: PMC8862090 DOI: 10.1136/annrheumdis-2021-221295] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/10/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance. METHODS We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). We evaluated person-time contributed while on the initial HCQ dose ('maintenance'), comparing this with person-time contributed after a first dose reduction, and after a first HCQ discontinuation. We estimated time to first flare, defined as either subsequent need for therapy augmentation, increase of ≥4 points in the SLE Disease Activity Index-2000, or hospitalisation for SLE. We estimated adjusted HRs (aHRs) with 95% CIs associated with reducing/discontinuing HCQ (vs maintenance). We also conducted separate multivariable hazard regressions in each HCQ subcohort to identify factors associated with flare. RESULTS We studied 1460 (90% female) patients initiating HCQ. aHRs for first SLE flare were 1.20 (95% CI 1.04 to 1.38) and 1.56 (95% CI 1.31 to 1.86) for the HCQ reduction and discontinuation groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts. CONCLUSIONS SLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.
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Affiliation(s)
- Celline C Almeida-Brasil
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Murray Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann Elaine Clarke
- Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Caroline Gordon
- Rheumatology Research Group, University of Birmingham, Birmingham, UK
| | | | - Michelle Petri
- Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ellen M Ginzler
- Medicine/Rheumatology, SUNY Downstate Medical Center, New York City, New York, USA
| | - D J Wallace
- Cedars-Sinai/David Geffen School of Medicine at UCLA, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sang-Cheol Bae
- Rheumatology, Hanyang University, Seongdong-gu, Seoul, The Republic of Korea
| | - Juanita Romero-Diaz
- Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Mary Anne Dooley
- Medicine, Unversity of North Carolina, Chapel Hill, North Carolina, USA
| | - Christine Peschken
- Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Isenberg
- Division of Medicine, University College London, London, UK
| | | | - Susan Manzi
- Allegheny Singer Research Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Sam Lim
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ronald F van Vollenhoven
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Ola Nived
- Rheumatology, Lund University, Lund, Sweden
| | - Andreas Jönsen
- Faculty of Medicine, Department of Clinical Sciences Lund, Section of Rheumatology, Lund University, Lund, Sweden
| | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Cynthia Aranow
- Northwell Health Feinstein Institutes for Medical Research Institute of Health Innovations and Outcomes Research, Manhasset, New York, USA
| | - Jorge Sanchez-Guerrero
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Paul R Fortin
- Medicine-Rheumatology, Université Laval, Quebec, Quebec, Canada
| | - Graciela S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Center for Health Promotion, Birmingham, Alabama, USA
| | - Joan T Merrill
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Kristján Steinsson
- Rheumatology, Department of Obstetrics and Gynecology, Landspitali University Hospital, Reyjavik, Iceland
| | - Asad Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, South Lanarkshire, UK
| | - Anca Askanase
- Rheumatology, Columbia University Medical Center, New York, New York, USA
| | | | - Ian N Bruce
- Arc Epidemiology Unit, The University of Manchester, Manchester, UK
| | - Murat Inanc
- Department of Internal Medicine, Division of Rheumatology, Istanbul University, Fatih, Istanbul, Turkey
| | - Michal Abrahamowicz
- Department of Epidemiology Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sasha Bernatsky
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Rheumatology, McGill University Health Centre, Montreal, Quebec, Canada
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Tayel SI, Muharram NM, Fotoh DS, Elbarbary HS, Abd-Elhafiz HI, El-Masry EA, Taha AE, Soliman SE. Prognostic Impact of Genetic Variants of MECP2 and TIRAP on Clinical Outcomes of Systemic Lupus Erythematosus with and without Nephritis. Biomolecules 2021; 11:1378. [PMID: 34572591 PMCID: PMC8466489 DOI: 10.3390/biom11091378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/11/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune illness with a growing prevalence in many populations. Few studies have examined genetic predisposition to SLE, so we aimed to examine the clinical impact of the genetic polymorphisms MECP2 rs2734647and TIRAP rs8177374 on the outcomes and therapeutic precision of SLE with and without nephritis. This study included 110 SLE patients-divided into 63 with lupus nephritis (LN), and 47 without nephritis-and 100 controls. Laboratory measurements including CRP, ESR, ACR, CBC, anti-ds-DNA, vitamin A, C3, and C4 were carried out, along with genotyping of MECP2 rs2734647and TIRAP rs8177374 by real-time PCR and sequencing. Treg %, vitamin A, C3, and C4 were lower, whereas Th17 % was higher, in patients vs. controls (p < 0.001). The T allele of MECP2 rs2734647 was higher in LN than in non-nephritis and control subjects. Moreover, the T allele of TIRAP rs8177374 was higher in LN than in non-nephritis and control subjects. The MECP2 and TIRAP genes could play a role in predisposition to SLE, and can also predict disease progress to nephritis, helping to personalize medicine.
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Affiliation(s)
- Safaa I. Tayel
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt; (N.M.M.); (S.E.S.)
- Medical Biochemistry Unit, College of Medicine, Al Baha University, Al Baha 65779, Saudi Arabia
| | - Nashwa M. Muharram
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt; (N.M.M.); (S.E.S.)
- Medical Biochemistry Unit, College of Medicine, Al Baha University, Al Baha 65779, Saudi Arabia
| | - Dina S. Fotoh
- Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt;
| | - Hany S. Elbarbary
- Renal Unit, Department of Internal Medicine, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt;
- Renal Unit, Department of Internal Medicine, College of Medicine, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - Huda I. Abd-Elhafiz
- Clinical Pharmacology Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt;
| | - Eman A. El-Masry
- Microbiology and Immunology Unit, Department of Pathology, College of Medicine, Jouf University, Sakaka 72388, Saudi Arabia; (E.A.E.-M.); (A.E.T.)
- Medical Microbiology and Immunology Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt
| | - Ahmed E. Taha
- Microbiology and Immunology Unit, Department of Pathology, College of Medicine, Jouf University, Sakaka 72388, Saudi Arabia; (E.A.E.-M.); (A.E.T.)
- Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa E. Soliman
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Menoufia University, Shebin el Kom 32511, Egypt; (N.M.M.); (S.E.S.)
- Medical Biochemistry Unit, Department of Pathology, College of Medicine, Qassim University, Buraydah 51452, Saudi Arabia
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5
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Isenberg D, Furie R, Jones NS, Guibord P, Galanter J, Lee C, McGregor A, Toth B, Rae J, Hwang O, Desai R, Lokku A, Ramamoorthi N, Hackney JA, Miranda P, de Souza VA, Jaller-Raad JJ, Maura Fernandes A, Garcia Salinas R, Chinn LW, Townsend MJ, Morimoto AM, Tuckwell K. Efficacy, Safety, and Pharmacodynamic Effects of the Bruton's Tyrosine Kinase Inhibitor Fenebrutinib (GDC-0853) in Systemic Lupus Erythematosus: Results of a Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Arthritis Rheumatol 2021; 73:1835-1846. [PMID: 34042314 DOI: 10.1002/art.41811] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/11/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Fenebrutinib (GDC-0853) is a noncovalent, oral, and highly selective inhibitor of Bruton's tyrosine kinase (BTK). The efficacy, safety, and pharmacodynamics of fenebrutinib in systemic lupus erythematosus (SLE) were assessed in this phase II, multicenter, randomized, placebo-controlled study. METHODS Patients who had moderately to severely active SLE while receiving background standard therapy were randomized to receive placebo, fenebrutinib 150 mg once daily, or fenebrutinib 200 mg twice daily. Glucocorticoid taper was recommended from weeks 0 to 12 and from weeks 24 to 36. The primary end point was the SLE Responder Index 4 (SRI-4) response at week 48. RESULTS Patients (n = 260) were enrolled from 44 sites in 12 countries, with the majority from Latin America, the US, and Western Europe. The SRI-4 response rates at week 48 were 51% for fenebrutinib 150 mg once daily (P = 0.37 versus placebo), 52% for fenebrutinib 200 mg twice daily (P = 0.34 versus placebo), and 44% for placebo. British Isles Lupus Assessment Group-based Combined Lupus Assessment response rates at week 48 were 53% for fenebrutinib 150 mg once daily (P = 0.086 versus placebo), 42% for fenebrutinib 200 mg twice daily (P = 0.879 versus placebo), and 41% for placebo. Safety results were similar across all arms, although serious adverse events were more frequent with fenebrutinib 200 mg twice daily. By week 48, patients treated with fenebrutinib had reduced levels of a BTK-dependent plasmablast RNA signature, anti-double-stranded DNA autoantibodies, total IgG, and IgM, as well as increased complement C4 levels, all relative to placebo. CONCLUSION While fenebrutinib had an acceptable safety profile, the primary end point, SRI-4 response, was not met despite evidence of strong pathway inhibition.
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Affiliation(s)
| | | | | | | | | | - Chin Lee
- Genentech, Inc., South San Francisco, California
| | | | - Balazs Toth
- Genentech, Inc., South San Francisco, California
| | - Julie Rae
- Genentech, Inc., South San Francisco, California
| | - Olivia Hwang
- Genentech, Inc., South San Francisco, California
| | - Rupal Desai
- Genentech, Inc., South San Francisco, California
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Pearce FA, Rutter M, Sandhu R, Batten RL, Garner R, Little J, Narayan N, Sharp CA, Bruce IN, Erb N, Griffiths B, Guest H, Macphie E, Packham J, Hiley C, Obrenovic K, Rivett A, Gordon C, Lanyon PC. BSR guideline on the management of adults with systemic lupus erythematosus (SLE) 2018: baseline multi-centre audit in the UK. Rheumatology (Oxford) 2021; 60:1480-1490. [PMID: 33291150 DOI: 10.1093/rheumatology/keaa759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/13/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published BSR guideline for the management of adults with SLE, the NICE technology appraisal for belimumab, and NHS England's clinical commissioning policy for rituximab. METHODS SLE cases attending outpatient clinics during any 4-week period between February and June 2018 were retrospectively audited to assess care at the preceding visit. The effect of clinical environment (general vs dedicated CTD/vasculitis clinic and specialized vs non-specialized centre) were tested. Bonferroni's correction was applied to the significance level. RESULTS Fifty-one units participated. We audited 1021 episodes of care in 1003 patients (median age 48 years, 74% diagnosed >5 years ago). Despite this disease duration, 286 (28.5%) patients had active disease. Overall in 497 (49%) clinic visits, it was recorded that the patient was receiving prednisolone, including in 28.5% of visits where disease was assessed as inactive. Low documented compliance (<60% clinic visits) was identified for audit standards relating to formal disease-activity assessment, reduction of drug-related toxicity and protection against comorbidities and damage. Compared with general clinics, dedicated clinics had higher compliance with standards for appropriate urine protein quantification (85.1% vs 78.1%, P ≤ 0.001). Specialized centres had higher compliance with BILAG Biologics Register recruitment (89.4% vs 44.4%, P ≤ 0.001) and blood pressure recording (95.3% vs 84.1%). CONCLUSIONS This audit highlights significant unmet need for better disease control and reduction in corticosteroid toxicity and is an opportunity to improve compliance with national guidelines. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery model.
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Affiliation(s)
- Fiona A Pearce
- Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Megan Rutter
- Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ravinder Sandhu
- Rheumatology, Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | - Rebecca L Batten
- Rheumatology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rozeena Garner
- Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jayne Little
- Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nehal Narayan
- Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Charlotte A Sharp
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust UK, Manchester, UK
| | - Ian N Bruce
- Manchester University NHS Foundation Trust UK, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Epidemiology Versus Arthritis, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Nicola Erb
- Rheumatology, Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | | | - Hannah Guest
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Macphie
- Rheumatology, Lancashire and South Cumbria NHS Foundation Trust, Preston, UK
| | - Jon Packham
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Rheumatology, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Chris Hiley
- British Society for Rheumatology, London, UK
| | - Karen Obrenovic
- Clinical Audit Department, Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | - Ali Rivett
- British Society for Rheumatology, London, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Peter C Lanyon
- Epidemiology and Public Health, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Rheumatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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7
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Almeida-Brasil CC, Pineau CA, Vinet E, Hanly JG, Peschken CA, Clarke AE, Fortin PR, Abrahamowicz M, Bernatsky S. Predictors of unsuccessful hydroxychloroquine tapering and discontinuation: Can we personalize decision-making in systemic lupus treatment? Arthritis Care Res (Hoboken) 2020; 74:1070-1078. [PMID: 33369255 PMCID: PMC9544951 DOI: 10.1002/acr.24548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/16/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
Objective Hydroxychloroquine (HCQ) is a key systemic lupus erythematosus (SLE) drug, making concerns of drug shortages grave. Our objective was to evaluate factors associated with poor outcomes after HCQ taper or discontinuation in SLE. Methods We studied 5 Canadian SLE cohorts between 1999 and 2019, following patients from the date of HCQ tapering (cohort 1) or discontinuation (cohort 2). A composite outcome was defined as any of the following: a need for therapy augmentation, an increase (of at least 4 points) in the Systemic Lupus Erythematosus Disease Activity Index 2000 score, or hospitalization for SLE. In each cohort, multivariable Cox regression was used to identify demographic and clinical factors associated with time to the earliest of these events. A third cohort continuing to receive HCQ was also studied, to assess whether the same factors influenced the outcome even when the HCQ dose was unchanged. Results The poor outcome rate, per 100 person‐years, was 35.7 (95% confidence interval [95% CI] 31.6–40.3) in the HCQ taper cohort (n = 398), 29.0 (95% CI 25.5–33.0) in the discontinuation cohort (n = 395), and 16.1 (95% CI 13.2–19.6) in the maintenance cohort (n = 395). In patients tapering HCQ, baseline prednisone use was independently associated with greater risk of poor outcomes. In the discontinuation cohort, the risk of poor outcomes was greater for Black patients and those diagnosed with SLE at age ≤25 years. Among those maintaining HCQ, baseline immunosuppressive use and First Nations ethnicity were associated with poor outcomes. Conclusion We identified demographic and clinical factors associated with poor outcomes after HCQ taper/discontinuation. This information is critical in the current setting of potential shortages, but over the long term, such information could inform personalized therapies.
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Affiliation(s)
- Celline C Almeida-Brasil
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Christian A Pineau
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Evelyne Vinet
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - John G Hanly
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Christine A Peschken
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Ann E Clarke
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Paul R Fortin
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Michal Abrahamowicz
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
| | - Sasha Bernatsky
- Department of Medicine, Division of Rheumatology and Division of Clinical Epidemiology and Centre for Outcomes Research and Evaluation, Research Institute, McGill University Health Centre, Quebec, Canada
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8
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Narváez J. Lupus eritematoso sistémico 2020. Med Clin (Barc) 2020; 155:494-501. [PMID: 32586673 DOI: 10.1016/j.medcli.2020.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
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Gavan S, Bruce I, Payne K. Generating evidence to inform health technology assessment of treatments for SLE: a systematic review of decision-analytic model-based economic evaluations. Lupus Sci Med 2020; 7:7/1/e000350. [PMID: 32723809 PMCID: PMC7389518 DOI: 10.1136/lupus-2019-000350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/05/2019] [Indexed: 11/22/2022]
Abstract
This study aimed to understand and appraise the approaches taken to handle the complexities of a multisystem disease in published decision-analytic model-based economic evaluations of treatments for SLE. A systematic review was conducted to identify all published model-based economic evaluations of treatments for SLE. Treatments that were considered for inclusion comprised antimalarial agents, immunosuppressive therapies, and biologics including rituximab and belimumab. Medline and Embase were searched electronically from inception until September 2018. Titles and abstracts were screened against the inclusion criteria by two reviewers; agreement between reviewers was calculated according to Cohen’s κ. Predefined data extraction tables were used to extract the key features, structural assumptions and data sources of input parameters from each economic evaluation. The completeness of reporting for the methods of each economic evaluation was appraised according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Six decision-analytic model-based economic evaluations were identified. The studies included azathioprine (n=4), mycophenolate mofetil (n=3), cyclophosphamide (n=2) and belimumab (n=1) as relevant comparator treatments; no economic evaluation estimated the relative cost-effectiveness of rituximab. Six items of the CHEERS statement were reported incompletely across the sample: target population, choice of comparators, measurement and valuation of preference-based outcomes, estimation of resource use and costs, choice of model, and the characterisation of heterogeneity. Complexity in the diagnosis, management and progression of disease can make decision-analytic model-based economic evaluations of treatments for SLE a challenge to undertake. The findings from this study can be used to improve the relevance of model-based economic evaluations in SLE and as an agenda for research to inform future health technology assessment and decision-making.
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Affiliation(s)
- Sean Gavan
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Ian Bruce
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Sapkota S, Baig S, Hess T, O'Connell AM, Menk J, Shyne M, Fazeli P, Ensrud K, Shmagel A. Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care? Lupus 2020; 29:263-272. [PMID: 31996109 DOI: 10.1177/0961203320903086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard. METHODS We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription. RESULTS A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098). CONCLUSIONS In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.
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Affiliation(s)
- S Sapkota
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
| | - S Baig
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - T Hess
- University of Minnesota Medical School, University of Minnesota, Minneapolis, USA
| | | | - J Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - M Shyne
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - P Fazeli
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
| | - K Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, USA.,Center for Care Delivery and Outcome Research, Minneapolis VA Health Care System, Minneapolis, USA
| | - A Shmagel
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
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Tani C, Elefante E, Signorini V, Zucchi D, Lorenzoni V, Carli L, Stagnaro C, Ferro F, Mosca M. Glucocorticoid withdrawal in systemic lupus erythematosus: are remission and low disease activity reliable starting points for stopping treatment? A real-life experience. RMD Open 2019; 5:e000916. [PMID: 31275608 PMCID: PMC6579574 DOI: 10.1136/rmdopen-2019-000916] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/02/2019] [Accepted: 05/09/2019] [Indexed: 12/26/2022] Open
Abstract
Objectives To evaluate the proportion of patients who have successfully withdrawn glucocorticoids (GCs) in a longitudinal cohort of patients with systemic lupus erythematosus (SLE) over a period of 6 years; to evaluate patient characteristics during GC withdrawal in relation to existing definitions of remission and Lupus Low Disease Activity State (LLDAS); and to evaluate the occurrence of flares after GC withdrawal. Methods Patients who attempted GC withdrawal were identified for the cohort, and the following information was assessed during withdrawal attempts: date of last disease flare, disease activity and damage and ongoing treatment. Information regarding the occurrence of disease flares after GC withdrawal was also recorded for patients who successfully stopped treatment.Definitions of remission were applied to GC withdrawal in line with European consensus criteria (Definitions of remission in SLE [DORIS]) and LLDAS in line with the Asian Pacific Lupus Consortium definition. Results 148 patients were involved in the study; GC withdrawal was attempted in 91 patients (61.5%) with 77 patients (84.6%) successfully stopping GCs. At the beginning of the GC reduction, the majority of patients were in complete or clinical remission (48.9% and 39.6%, respectively). Disease activity was significantly lower in patients who successfully stopped GCs, and the proportion of patients in complete remission was higher (54.2%) with respect to patients who failed in their attempt. Among patients who stopped GCs, 18 flares were recorded after a median of 1 year. The time period since the last flare was shorter in patients who experienced flares with respect to patients who did not flare (mean 0.93 years vs 6.0, p<0.001). Conclusions GC withdrawal is an achievable goal in SLE and may be attempted after a long-term remission or LLDAS to protect the patient from disease flares.
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Affiliation(s)
- Chiara Tani
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Viola Signorini
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dina Zucchi
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Linda Carli
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Chiara Stagnaro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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