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Golder V, Kandane-Rathnayake R, Louthrenoo W, Chen YH, Cho J, Lateef A, Hamijoyo L, Luo SF, Wu YJJ, Navarra SV, Zamora L, Li Z, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake BMDB, Chan M, Kikuchi J, Takeuchi T, Bae SC, Oon S, O'Neill S, Goldblatt F, Ng KPL, Law A, Tugnet N, Kumar S, Tee C, Tee M, Ohkubo N, Tanaka Y, Lau CS, Nikpour M, Hoi A, Morand EF. Comparison of Attainment and Protective Effects of Lupus Low Disease Activity State In Patients With Newly Diagnosed Versus Established Systemic Lupus Erythematosus. J Rheumatol 2024:jrheum.2023-0900. [PMID: 38490668 DOI: 10.3899/jrheum.2023-0900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To assess whether Lupus Low Disease Activity State (LLDAS) attainment is associated with favorable outcomes in patients with recent onset systemic lupus erythematosus (SLE). METHODS Data from a 13-country longitudinal SLE cohort were collected prospectively between 2013 and 2020. An inception cohort was defined based on disease duration < 1 year at enrollment. Patient characteristics between inception and noninception cohorts were compared. Survival analyses were performed to examine the association between LLDAS attainment and damage accrual and flare. RESULTS Of the total 4106 patients, 680 (16.6%) were recruited within 1 year of SLE diagnosis (inception cohort). Compared to the noninception cohort, inception cohort patients were significantly younger, had higher disease activity, and used more glucocorticoids, but had less organ damage at enrollment. Significantly fewer inception cohort patients were in LLDAS at enrollment than the noninception cohort (29.6% vs 52.3%, P < 0.001), but three-quarters of both groups achieved LLDAS at least once during follow-up. Limiting analysis only to patients not in LLDAS at enrollment, inception cohort patients were 60% more likely to attain LLDAS (hazard ratio 1.37, 95% CI 1.16-1.61, P < 0.001) than noninception cohort patients and attained LLDAS significantly faster. LLDAS attainment was significantly protective against flare in both the inception and noninception cohorts. A total of 88 (13.6%) inception cohort patients accrued organ damage during a median 2.2 years of follow-up. CONCLUSION LLDAS attainment is protective from flare in recent onset SLE. Significant protection from damage accrual was not observed because of low rates of damage accrual in the first years after SLE diagnosis. (ClinicalTrials.gov: NCT03138941).
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Affiliation(s)
- Vera Golder
- V. Golder, MBBS, PhD, Monash University, Melbourne, Australia
| | | | - Worawit Louthrenoo
- W. Louthrenoo, MD, Faculty of Medicine, Chiang Mai University, Chang Mai, Thailand
| | - Yi-Hsing Chen
- Y.H. Chen, MD, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiacai Cho
- J. Cho, MBBS, National University Hospital, Singapore
| | - Aisha Lateef
- A. Lateef, MBBS, National University Hospital, Singapore
| | | | - Shue-Fen Luo
- S.F. Luo, MD, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yeong-Jian J Wu
- Y.J.J. Wu, MD, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sandra V Navarra
- S.V. Navarra, MD, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- L. Zamora, MD, University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- Z. Li, MD, People's Hospital Peking University Health Sciences Centre, Beijing, China
| | | | | | | | - Yanjie Hao
- Y. Hao, MD, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Z. Zhang, MD, Peking University First Hospital, Beijing, China
| | | | | | - Jun Kikuchi
- J. Kikuchi, MD, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- T. Takeuchi, MD, Keio University, Tokyo, and Saitama Medical University, Saitama, Japan
| | - Sang-Cheol Bae
- S.C. Bae, MD, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research, and Hanyang University Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - Shereen Oon
- S. Oon, MBBS, PhD, Department of Medicine, University of Melbourne at St Vincent's Hospital, Fitzroy, Australia
| | - Sean O'Neill
- S. O'Neill, BMed, PhD, University of New South Wales and Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Fiona Goldblatt
- F. Goldblatt, MBBS, PhD, Royal Adelaide Hospital and Flinders Medical Centre, Bedford Park, Australia
| | | | - Annie Law
- A. Law, MBBS, Singapore General Hospital, Singapore
| | - Nicola Tugnet
- N. Tugnet, MBCHB, Auckland District Health Board, Auckland, New Zealand
| | - Sunil Kumar
- S. Kumar, MBBS, Middlemore Hospital, Auckland, New Zealand
| | - Cherica Tee
- C. Tee, MD, University of the Philippines, Quezon City, Philippines
| | - Michael Tee
- M. Tee, MD, University of the Philippines, Quezon City, Philippines
| | - Naoaki Ohkubo
- N. Ohkubo, MD, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- Y. Tanaka, MD, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | - Mandana Nikpour
- M. Nikpour, MBBS, PhD, University of Melbourne at St Vincent's Hospital, Fitzroy, Australia
| | - Alberta Hoi
- A. Hoi, MBBS, PhD, Monash University, Melbourne, Australia
| | - Eric F Morand
- E.F. Morand, MBBS, PhD, Monash University, Melbourne, Australia
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Yeo AL, Kandane-Rathnayake R, Koelmeyer R, Golder V, Louthrenoo W, Chen YH, Cho J, Lateef A, Hamijoyo L, Luo SF, Wu YJJ, Navarra SV, Zamora L, Li Z, An Y, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake BMDB, Chan M, Kikuchi J, Takeuchi T, Bae SC, Oon S, O'Neill S, Goldblatt F, Ng KPL, Law A, Tugnet N, Kumar S, Tee C, Tee M, Ohkubo N, Tanaka Y, Lau CS, Nikpour M, Hoi A, Leech M, Morand EF. SMART-SLE: serology monitoring and repeat testing in systemic lupus erythematosus-an analysis of anti-double-stranded DNA monitoring. Rheumatology (Oxford) 2024; 63:525-533. [PMID: 37208196 PMCID: PMC10836977 DOI: 10.1093/rheumatology/kead231] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Disease activity monitoring in SLE includes serial measurement of anti-double stranded-DNA (dsDNA) antibodies, but in patients who are persistently anti-dsDNA positive, the utility of repeated measurement is unclear. We investigated the usefulness of serial anti-dsDNA testing in predicting flare in SLE patients who are persistently anti-dsDNA positive. METHODS Data were analysed from patients in a multinational longitudinal cohort with known anti-dsDNA results from 2013 to 2021. Patients were categorized based on their anti-dsDNA results as persistently negative, fluctuating or persistently positive. Cox regression models were used to examine longitudinal associations of anti-dsDNA results with flare. RESULTS Data from 37 582 visits of 3484 patients were analysed. Of the patients 1029 (29.5%) had persistently positive anti-dsDNA and 1195 (34.3%) had fluctuating results. Anti-dsDNA expressed as a ratio to the normal cut-off was associated with the risk of subsequent flare, including in the persistently positive cohort (adjusted hazard ratio [HR] 1.56; 95% CI: 1.30, 1.87; P < 0.001) and fluctuating cohort (adjusted HR 1.46; 95% CI: 1.28, 1.66), both for a ratio >3. Both increases and decreases in anti-dsDNA more than 2-fold compared with the previous visit were associated with increased risk of flare in the fluctuating cohort (adjusted HR 1.33; 95% CI: 1.08, 1.65; P = 0.008) and the persistently positive cohort (adjusted HR 1.36; 95% CI: 1.08, 1.71; P = 0.009). CONCLUSION Absolute value and change in anti-dsDNA titres predict flares, including in persistently anti-dsDNA positive patients. This indicates that repeat monitoring of dsDNA has value in routine testing.
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Affiliation(s)
- Ai Li Yeo
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Rangi Kandane-Rathnayake
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Rachel Koelmeyer
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Worawit Louthrenoo
- Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiacai Cho
- Rheumatology Divsion, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Divsion, National University Hospital, Singapore
| | - Laniyati Hamijoyo
- Department of Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Shue-Fen Luo
- Department of Rheumatology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Yeong-Jian J Wu
- Department of Rheumatology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Sandra V Navarra
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Yuan An
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Sciences Centre, Beijing, China
| | | | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yanjie Hao
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | | | - Madelynn Chan
- Department of Rheumatology, Allergy and Immunology Tan Tock Seng Hospital, Singapore
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology Research and Hanyang University Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - Shereen Oon
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Sean O'Neill
- Rheumatology Department, Level 1 Liverpool Hospital, Liverpool, NSW, Australia
| | - Fiona Goldblatt
- Rheumatology Unit, Royal Adelaide Hospital and Flinders Medical Centre, Adelaide, South Australia, Australia
| | | | - Annie Law
- Singapore General Hospital, Singapore
| | - Nicola Tugnet
- Department of Rheumatology, Auckland District Health Board, Auckland, New Zealand
| | - Sunil Kumar
- Department of Rheumatology, Middlemore Hospital, Auckland, New Zealand
| | - Cherica Tee
- University of the Philippines, Quezon City, Philippines
| | - Michael Tee
- University of the Philippines, Quezon City, Philippines
| | - Naoaki Ohkubo
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, University of Hong Kong, Hong Kong, Hong Kong, China
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Alberta Hoi
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Michelle Leech
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
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Cho J, Shen L, Huq M, Kandane-Rathnayake R, Golder V, Louthrenoo W, Chen YH, Hamijoyo L, Luo SF, Wu YJJ, Zamora L, Li Z, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake D, Chan M, Kikuchi J, Takeuchi T, Bae SC, Oon S, O'Neill S, Goldblatt F, Ng KPL, Law A, Tugnet N, Kumar S, Tee C, Tee M, Ohkubo N, Tanaka Y, Navarra SV, Lau CS, Hoi A, Morand EF, Nikpour M, Lateef A. Impact of low disease activity, remission, and complete remission on flares following tapering of corticosteroids and immunosuppressive therapy in patients with systemic lupus erythematous: a multinational cohort study. Lancet Rheumatol 2023; 5:e584-e593. [PMID: 38251484 DOI: 10.1016/s2665-9913(23)00209-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/20/2023] [Accepted: 07/27/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Targets of treatment for systemic lupus erythematosus (SLE) include the Lupus Low Disease Activity State (LLDAS), remission, and complete remission. Whether treatment can be tapered after attaining these targets and whether tapering is safer in patients in complete remission compared with LLDAS are unknown. We aimed to assess the odds of disease flares after treatment tapering in stable disease, versus continuing the same therapy. We also aimed to examine whether tapering in complete remission resulted in fewer flares or longer time to flare compared with tapering in LLDAS or remission. METHODS This multinational cohort study was conducted at 25 sites across 13 Asia-Pacific countries. We included adult patients aged 18 years or older with stable SLE who were receiving routine clinical care, had two or more visits and had attained stable disease at one or more visits. We categorised stable disease into: LLDAS (Systemic Lupus Erythematosus Disease Activity Index 2000 [SLEDAI-2K] score ≤4, Physician Global Assessment [PGA] ≤1, and prednisolone ≤7·5 mg/day); Definitions of Remission in SLE (DORIS) remission (clinical SLEDAI-2K score 0, PGA <0·5, and prednisolone ≤5 mg/day); or complete remission on therapy (SLEDAI-2K score 0, PGA <0·5, and prednisolone ≤5 mg/day). Stable disease categories were mutually exclusive. Tapering was defined as any decrease in dose of corticosteroids or immunosuppressive therapy (mycophenolate mofetil, calcineurin inhibitors, azathioprine, leflunomide, or methotrexate). Using multivariable generalised estimating equations, we compared flares (SELENA-SLEDAI Flare Index) at the subsequent visit after drug tapering. We used generalised estimating equations and Cox proportional hazard models to compare tapering attempts that had begun in LLDAS, remission, and complete remission. FINDINGS Between May 1, 2013, and Dec 31, 2020, 4106 patients were recruited to the cohort, 3002 (73·1%) of whom were included in our analysis. 2769 (92·2%) participants were female, 233 (7·8%) were male, and 2636 (88·1%) of 2993 with ethnicity data available were Asian. The median age was 39·5 years (IQR 29·0-50·0). There were 14 808 patient visits for patients in LLDAS, or remission or complete remission, of which 13 140 (88·7%) entered the final multivariable model after excluding missing data. Among the 9863 visits at which patients continued the same therapy, 1121 (11·4%) flared at the next visit, of which 221 (19·7%) were severe flares. Of the 3277 visits at which a patient received a tapering of therapy, 557 (17·0%) flared at the next visit, of which 120 (21·5%) were severe flares. Tapering was associated with higher odds of flare compared with continuing the same therapy (odds ratio [OR] 1·24 [95% CI 1·10-1·39]; p=0·0005). Of 2095 continuous tapering attempts, 860 (41·1%) were initiated in LLDAS, 596 (28·4%) in remission, and 639 (30·5%) in complete remission. Tapering initiated in LLDAS (OR 1·37 [95% CI 1·03-1·81]; p=0·029) or remission (1·45 [1·08-1·94]; p=0·013) had higher odds of flare in 1 year compared with complete remission. Tapering in LLDAS (hazard ratio 1·24 [95% CI 1·04-1·48]; p=0·016) or remission (1·30 [1·08-1·56]; p=0·0054) had a significantly shorter time to first flare than tapering initiated in complete remission. Attaining sustained LLDAS, remission, or complete remission for at least 6 months just before the time of taper was associated with lower odds of flare at next visit, flares in 1 year, and longer time to flare. INTERPRETATION Tapering of corticosteroids or immunosuppressive therapy in patients with stable SLE was associated with excess flares. Our findings suggest that drug tapering should be carefully considered, weighing the risks and benefits, and is best exercised in complete (clinical and serological) remission and after maintaining stable disease for at least 6 months. FUNDING AstraZeneca, BMS, Eli Lily, Janssen, Merck Serono, GSK, and UCB.
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Affiliation(s)
- Jiacai Cho
- National University Hospital, Singapore.
| | - Liang Shen
- National University of Singapore, Singapore
| | - Molla Huq
- The University of Melbourne, Melbourne, VIC, Australia
| | | | - Vera Golder
- Monash University, Melbourne, VIC, Australia
| | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan
| | | | | | | | - Leonid Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Beijing, China
| | | | | | | | - Yanjie Hao
- Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Peking University First Hospital, Beijing, China
| | | | | | - Jun Kikuchi
- Keio University and Saitama Medical University, Saitama, Tokyo, Japan
| | | | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Shereen Oon
- Department of Medicine, The University of Melbourne at St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Sean O'Neill
- Department of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Fiona Goldblatt
- Royal Adelaide Hospital and Flinders Medical Centre, Adelaide, SA, Australia
| | | | - Annie Law
- Singapore General Hospital, Singapore
| | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | | | - Cherica Tee
- University of the Philippines, Manila, Philippines
| | - Michael Tee
- University of the Philippines, Manila, Philippines
| | - Naoaki Ohkubo
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | - Chak Sing Lau
- University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Alberta Hoi
- Monash University, Melbourne, VIC, Australia
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Connelly K, Kandane-Rathnayake R, Hoi A, Louthrenoo W, Hamijoyo L, Luo SF, Wu YJJ, Cho J, Lateef A, Lau CS, Chen YH, Navarra S, Zamora L, Li Z, An Y, Sockalingam S, Hao Y, Zhang Z, Chan M, Katsumata Y, Harigai M, Oon S, Bae SC, O'Neill S, Gibson KA, Basnayake B, Kikuchi J, Takeuchi T, Ng KPL, Tugnet N, Kumar S, Goldblatt F, Law A, Tee M, Tee C, Tanaka Y, Ohkubo N, Tan JY, Karyekar CS, Nikpour M, Golder V, Morand EF. Association of Modified Systemic Lupus Erythematosus Responder Index Attainment With Long-Term Clinical Outcomes: A Five-Year Prospective Study. Arthritis Rheumatol 2023; 75:401-410. [PMID: 36122172 DOI: 10.1002/art.42350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/22/2022] [Accepted: 09/07/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE In trials of systemic lupus erythematosus (SLE), the SLE Responder Index (SRI) is the most commonly used primary efficacy end point but has limited validation against long-term outcomes. We aimed to investigate associations of attainment of a modified version of the SRI (mSRI) with key clinical outcomes in SLE patients with up to 5 years of follow-up. METHODS We used data from a large multicenter, longitudinal SLE cohort in which patients received standard of care. The first visit with active disease (defined as SLE Disease Activity Index 2000 [SLEDAI-2K] score ≥6) was designated as baseline, and mSRI attainment (defined as a reduction in SLEDAI-2K ≥4 points with no worsening in physician global assessment ≥0.3 points) was determined at annual intervals from baseline up to 5 years. Associations between mSRI attainment and outcomes including disease activity, glucocorticoid dose, flare, damage accrual, Lupus Low Disease Activity State (LLDAS), and remission were studied. RESULTS We included 2,060 patients, with a median baseline SLEDAI-2K score of 8. An mSRI response was attained by 56% of patients at 1 year, with similar responder rates seen at subsequent annual time points. Compared to nonresponders, mSRI responders had significantly lower disease activity and prednisolone dose and higher proportions of LLDAS and remission attainment at each year, and less damage accrual at years 2 and 3. Furthermore, mSRI responder status at 1 year predicted clinical benefit at subsequent years across most outcomes, including damage accrual (odds ratio [OR] range 0.58-0.69, P < 0.05 for damage accrual ORs at all time points). CONCLUSION In SLE patients with active disease receiving standard of care, mSRI attainment predicts favorable outcomes over long-term follow-up, supporting the clinical meaningfulness of SRI attainment as an SLE trial end point.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Alberta Hoi
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Worawit Louthrenoo
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Department of Internal Medicine, Faculty of Medicine, Padjadjaran University/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
| | - Yeong-Jian Jan Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
| | - Jiacai Cho
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - C S Lau
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sandra Navarra
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Science Center, Beijing, China
| | - Yuan An
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Science Center, Beijing, China
| | - Sargunan Sockalingam
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yanjie Hao
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore
| | - Madelynn Chan
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine
| | - Yasuhiro Katsumata
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine
| | - Shereen Oon
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases and Hanyang University Institute for Rheumatology Research, Seoul, Korea
| | - Sean O'Neill
- Rheumatology Department, Liverpool Hospital, and University of New South Wales and Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia
| | - Kathryn A Gibson
- Rheumatology Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Bmdb Basnayake
- Division of Nephrology, Teaching Hospital, Kandy, Sri Lanka
| | - Jun Kikuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | | | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | | | - Fiona Goldblatt
- Department of Rheumatology, Flinders Medical Centre, Bedford Park, and Rheumatology Unit, Royal Adelaide Hospital, North Terrace, South Australia, Australia
| | - Annie Law
- Singapore General Hospital, Singapore
| | - Michael Tee
- University of the Philippines, Manila, Philippines
| | - Cherica Tee
- University of the Philippines, Manila, Philippines
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Naoaki Ohkubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Mandana Nikpour
- Department of Rheumatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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5
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Kandane-Rathnayake R, Golder V, Louthrenoo W, Chen YH, Cho J, Lateef A, Hamijoyo L, Luo SF, Wu YJJ, Navarra SV, Zamora L, Li Z, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake BMDB, Chan M, Kikuchi J, Takeuchi T, Bae SC, Oon S, O'Neill S, Goldblatt F, Ng KPL, Law A, Tugnet N, Kumar S, Tee C, Tee M, Ohkubo N, Tanaka Y, Yu D, Karyekar CS, Sing Lau C, Monk JA, Nikpour M, Hoi A, Morand EF. Lupus low disease activity state and remission and risk of mortality in patients with systemic lupus erythematosus: a prospective, multinational, longitudinal cohort study. Lancet Rheumatol 2022; 4:e822-e830. [PMID: 38261390 DOI: 10.1016/s2665-9913(22)00304-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Treat-to-target goals for patients with systemic lupus erythematosus (SLE) have been validated to protect against organ damage and to improve quality of life. We aimed to investigate the association between lupus low disease activity state (LLDAS) and remission and risk of mortality in patients with SLE. We hypothesised that LLDAS has a protective association with mortality risk. METHODS In this prospective, multinational, longitudinal cohort study, we used data from patients with SLE in the Asia Pacific Lupus Collaboration cohort collected between May 1, 2013, and Dec 31, 2020. Eligible patients were adults (aged ≥18 years) who met either the 1997 American College of Rheumatology modified classification criteria for SLE or the 2012 Systemic Lupus International Collaborating Clinics classification criteria. The primary outcome was all-cause mortality, and LLDAS, remission, and variations of remission with lower glucocorticoid thresholds were the primary exposure variables. Survival analyses were used to examine longitudinal associations between these endpoints and risk of mortality. This study is registered with ClinicalTrials.gov, NCT03138941. FINDINGS Among a total of 4106 patients in the cohort, 3811 (92·8%) patients were included in the final analysis (median follow-up 2·8 years [IQR 1·0-5·3]; 3509 [92·1%] women and 302 [7·9%] men), of whom 80 died during the observation period (crude mortality rate 6·4 deaths per 1000 person-years). LLDAS was attained at least once in 43 (53·8%) of 80 participants who died and in 3035 (81·3%) of 3731 participants who were alive at the end of the study (p<0·0001); 22 (27·5%) participants who died versus 1966 (52·7%) who were alive at the end of the study attained LLDAS for at least 50% of observed time (p<0·0001). Remission was attained by 32 (40·0%) of 80 who died and in 2403 (64·4%) of 3731 participants who were alive at the end of the study (p<0·0001); 14 (17·5%) participants who died versus 1389 (37·2%) who were alive at the end of the study attained remission for at least 50% of observed time (p<0·0001). LLDAS for at least 50% of observed time (adjusted hazard ratio 0·51 [95% CI 0·31-0·85]; p=0·010) and remission for at least 50% of observed time (0·52 [0·29-0·93]; p=0·027) were associated with reduced risk of mortality. Modifying the remission glucocorticoid threshold (<5·0 mg/day prednisolone) was more protective against mortality than current remission definitions (0·31 [0·12-0·77]; p=0·012), and glucocorticoid-free remission was the most protective (0·13 [0·02-0·96]; p=0·046). INTERPRETATION LLDAS significantly reduced the risk of mortality in patients with SLE. Remission did not further reduce the risk of mortality compared with LLDAS, unless lower glucocorticoid thresholds were used. FUNDING The Asia-Pacific Lupus Collaboration received funding from Janssen, Bristol Myers Squibb, Eli Lilly, and UCB for this study.
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Affiliation(s)
| | - Vera Golder
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiacai Cho
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Laniyati Hamijoyo
- Department of Internal Medicine, Faculty of Medicine, University of Padjadjaran, Sumedang, Indonesia
| | - Shue-Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yeong-Jian J Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Sandra V Navarra
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Joint and Bone Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Bejing, China
| | - Sargunan Sockalingam
- Department of Rheumatology and Immunology, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Yanjie Hao
- Institute of Rheumatology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Institute of Rheumatology, Peking University First Hospital, Beijing, China
| | | | | | - Jun Kikuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan; Saitama Medical University, Saitama, Japan
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang University Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - Shereen Oon
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, VIC, Australia
| | - Sean O'Neill
- Department of Medicine, University of New South Wales, Kensington, NSW, Australia; Musculoskeletal flagship, University of Sydney, Camperdown, NSW, Australia
| | - Fiona Goldblatt
- Royal Adelaide Hospital and Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Annie Law
- Singapore General Hospital, Singapore
| | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | - Sunil Kumar
- Department of Rheumatology, Middlemore Hospital, Auckland, New Zealand
| | - Cherica Tee
- Department of Medicine, University of the Philippines, Quezon City, Philippines
| | - Michael Tee
- Department of Medicine, University of the Philippines, Quezon City, Philippines
| | - Naoaki Ohkubo
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Chak Sing Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pok Fu Lam, Hong Kong Special Administrative Region, China
| | - Julie A Monk
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Mandana Nikpour
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, VIC, Australia
| | - Alberta Hoi
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, Australia.
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6
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Connelly K, Kandane-Rathnayake R, Hoi A, Louthrenoo W, Hamijoyo L, Cho J, Lateef A, Fen Luo S, Wu YJJ, Li Z, Navarra S, Zamora L, Sockalingam S, Hao Y, Zhang Z, Katsumata Y, Harigai M, Oon S, Chan M, Chen YH, Bae SC, O'Neill S, Goldblatt F, Kikuchi J, Takeuchi T, Ling Ng KP, Tugnet N, Basnayake BMDB, Ohkubo N, Tanaka Y, Sing Lau C, Nikpour M, Golder V, Morand EF. Associations of improvement in laboratory tests with clinical outcomes in patients with active systemic lupus erythematosus: a multinational longitudinal cohort study. Lancet Rheumatol 2022; 4:e831-e841. [PMID: 38261391 DOI: 10.1016/s2665-9913(22)00307-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The selection and categorisation of laboratory tests in disease activity measures used within systemic lupus erythematosus (SLE) trial endpoints lack strong evidence. We aimed to determine whether longitudinal improvements in routinely measured laboratory tests are associated with measures of clinical improvement in patients with baseline active SLE. METHODS We included patients from a multicentre longitudinal cohort (recruited between May 1, 2013, and Dec 31, 2019) with active SLE (SLEDAI-2K ≥6) coinciding with an abnormality in at least one of 13 routine laboratory tests, at a visit designated as baseline. At 12 months, we analysed associations between thresholds of improvement in individual laboratory test results, measured as continuous variables, and five clinical outcomes using logistic regression. Primary outcomes were damage accrual and lupus low disease activity state (LLDAS), and secondary outcomes were modified SLE responder index (mSRI), physician global assessment (PGA) improvement of at least 0·3, and flare. FINDINGS We included 1525 patients (1415 [93%] women and 110 [7%] men, 1328 [87%] Asian ethnicity) in separate subsets for each laboratory test. The strongest associations with LLDAS and damage protection were seen with improvements in proteinuria (complete response: adjusted odds ratio [OR] 62·48, 95% CI 18·79-208·31 for LLDAS, OR 0·22, 95% CI 0·10-0·49 for damage accrual), albumin (complete response: adjusted OR 6·46, 95% CI 2·20-18·98 for LLDAS, OR 0·42, 95% CI 0·20-1·22 for damage accrual), haemoglobin (complete response: adjusted OR 1·97, 95% CI 1·09-3·53 for LLDAS, OR 0·33, 95% CI 0·15-0·71 for damage accrual), erythrocyte sedimentation rate (complete response: adjusted OR 1·71, 95% CI 1·10-2·67 for LLDAS, OR 0·53, 95% CI 0·30-0·94 for damage accrual), and platelets (complete response: adjusted OR 4·82, 95% CI 1·54-15·07 for LLDAS, OR 0·49, 95% CI 0·20-1·19 for damage accrual). Improvement in serological tests were mainly associated with PGA and mSRI. White cell and lymphocyte count improvements were least predictive. INTERPRETATION Improvements in several routine laboratory tests correspond with clinical outcomes in SLE over 12 months. Tests with the strongest associations were discrepant with laboratory tests included in current trial endpoints, and associations were observed across a range of improvement thresholds including incomplete resolution. These findings suggest the need to revise the use of laboratory test results in SLE trial endpoints. FUNDING Abbvie.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
| | | | - Alberta Hoi
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Division of Rheumatology, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Jiacai Cho
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Aisha Lateef
- Rheumatology Division, University Medical Cluster, National University Hospital, Singapore
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yeong-Jian J Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Zhanguo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Science Center, Beijing, China
| | - Sandra Navarra
- Bone and Joint Center, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Bone and Joint Center, University of Santo Tomas Hospital, Manila, Philippines
| | | | - Yanjie Hao
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shereen Oon
- Department of Rheumatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Madelynn Chan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sean O'Neill
- Rheumatology Department, Liverpool Hospital, Liverpool, NSW, Australia
| | - Fiona Goldblatt
- Department of Rheumatology, Flinders Medical Centre and Royal Adelaide Hospital, Bedford Park, SA, Australia
| | - Jun Kikuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University, Tokyo, Japan
| | | | - Nicola Tugnet
- Department of Rheumatology, Greenlane Clinical Centre, Auckland, New Zealand
| | | | - Naoaki Ohkubo
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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7
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Cho J, Kandane-Rathnayake R, Louthrenoo W, Hoi A, Golder V, Chen YH, Luo SF, Wu YJJ, Hamijoyo L, Lau CS, Navarra S, Zamora L, Tee M, Flora A, Li ZG, An Y, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Kikuchi J, Takeuchi T, Basnayake D, Goldblatt F, Chan M, Ng KPL, Bae SC, Oon S, O'Neill S, Gibson K, Kumar S, Law AHN, Tugnet N, Tanaka Y, Nikpour M, Morand E, Lateef A. COVID-19 infection in patients with systemic lupus erythematosus: Data from the Asia Pacific Lupus Collaboration. Int J Rheum Dis 2020; 23:1255-1257. [PMID: 32841510 PMCID: PMC7461525 DOI: 10.1111/1756-185x.13937] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jiacai Cho
- National University Hospital, Singapore, Singapore
| | | | | | | | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan
| | | | | | - Laniyati Hamijoyo
- Padjadjaran University/Hasan Sadikin General Hospital, Bandung, Indonesia
| | | | | | - Leonid Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | - Michael Tee
- University of the Philippines, Manila, Philippines
| | | | - Zhan-Guo Li
- People's Hospital, Peking University Health Science Center, Beijing, China
| | - Yuan An
- People's Hospital, Peking University Health Science Center, Beijing, China
| | | | | | | | - Yanjie Hao
- Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Peking University First Hospital, Beijing, China
| | | | | | | | - Fiona Goldblatt
- Royal Adelaide Hospital And Flinders Medical Centre, Adelaide, Australia
| | | | | | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seongdong-gu, Republic of Korea
| | - Shereen Oon
- St. Vincent's Hospital, Melbourne, Australia
| | | | | | | | | | - Nicola Tugnet
- Auckland District Health Board, Auckland, New Zealand
| | - Yoshiya Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Aisha Lateef
- National University Hospital, Singapore, Singapore
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