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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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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:ard-2023-225369. [PMID: 38423757 DOI: 10.1136/ard-2023-225369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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3
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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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4
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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, Eades LE, Koelmeyer R, Ayton D, Golder V, Kandane-Rathnayake R, Gregory K, Brunner H, Burke L, Arnaud L, Askanase A, Aranow C, Vital E, Pons-Estel G, Dantata K, Andersen J, Cornet A, Buie J, Sun Y, Tanaka Y, Simon L, Lahoud Y, Friedman A, Kalunian K, Zuraw Q, Werth V, Garces S, Morand EF. Towards a novel clinical outcome assessment for systemic lupus erythematosus: first outcomes of an international taskforce. Nat Rev Rheumatol 2023; 19:592-602. [PMID: 37433880 DOI: 10.1038/s41584-023-00993-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/13/2023]
Abstract
Systemic lupus erythematosus (SLE) is a disease of high unmet therapeutic need. The challenge of accurately measuring clinically meaningful responses to treatment has hindered progress towards positive outcomes in SLE trials, impeding the approval of potential new therapies. Current primary end points used in SLE trials are based on legacy disease activity measures that were neither specifically designed for the clinical trial context, nor developed according to contemporary recommendations for clinical outcome assessments (COAs), such as that substantial patient input should be incorporated into their design. The Treatment Response Measure for SLE (TRM-SLE) Taskforce is a global collaboration of SLE clinician-academics, patients and patient representatives, industry partners and regulatory experts, established to realize the goal of developing a new COA for SLE clinical trials. The aim of this project is a novel COA designed specifically to measure treatment effects that are clinically meaningful to patients and clinicians, and intended for implementation in a trial end point that supports regulatory approval of novel therapeutic agents in SLE. This Consensus Statement reports the first outcomes of the TRM-SLE project, including a structured process for TRM-SLE development.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
| | - Laura E Eades
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Rachel Koelmeyer
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Vera Golder
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | | | - Kate Gregory
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital, University of Cincinnati, Cincinatti, OH, USA
| | | | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases (RESO), Hopitaux Universitaires de Strasbourg, Strasbourg, Alsace, France
| | - Anca Askanase
- Lupus Center, Columbia University Medical Center, New York City, NY, USA
| | - Cynthia Aranow
- Lupus Centre of Excellence, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ed Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Guillermo Pons-Estel
- Departamento de Medicina Interna, Centro Regional de Enfermedades Autoinmunes y Reumáticas de Grupo Oroño (GO CREAR), Rosario, Argentina
| | | | | | | | - Joy Buie
- Lupus Foundation of America, Washington, DC, USA
| | - Ying Sun
- Merck Healthcare KGaA, Darmstadt, Hesse, Germany
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Fukuoka, Japan
| | | | | | | | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, CA, USA
| | - Qing Zuraw
- Janssen Research and Development, Spring House, PA, USA
| | - Victoria Werth
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Eric F Morand
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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6
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Morand EF, Abreu G, Furie RA, Golder V, Tummala R. Lupus low disease activity state attainment in the phase 3 TULIP trials of anifrolumab in active systemic lupus erythematosus. Ann Rheum Dis 2023; 82:639-645. [PMID: 36690388 PMCID: PMC10176410 DOI: 10.1136/ard-2022-222748] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 05/03/2022] [Accepted: 12/15/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES In patients with systemic lupus erythematosus (SLE), lupus low disease activity state (LLDAS) attainment is associated with improved outcomes. We investigated LLDAS attainment in anifrolumab-treated patients. METHODS We performed post hoc analysis of pooled Treatment of Uncontrolled Lupus via the Interferon Pathway (TULIP-1) (NCT02446912) and TULIP-2 (NCT02446899) anifrolumab phase 3 trial data in patients with moderate to severe SLE receiving standard therapy. LLDAS was defined as: SLE Disease Activity Index 2000 ≤4 without major organ activity, no new disease activity, Physician's Global Assessment ≤1, prednisone ≤7.5 mg/day and no non-standard immunosuppressant dosing. Time to first LLDAS attainment was compared between groups using Cox regression modelling; responses were compared using logistic regression. RESULTS Agnostic to treatment, 205/819 (25.0%) patients attained LLDAS at week 52; 186/205 (90.7%) were also British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA)-responders. Among BICLA-responders at week 52, 186/318 (58.5%) attained LLDAS; 203/380 (53.4%) SLE Responder Index-4 (SRI(4)) responders attained LLDAS. Improvements from baseline in patient global assessment scores at week 52 were threefold greater in LLDAS-attainers. At week 52, 30.0% of anifrolumab-treated patients and 19.6% of placebo were in LLDAS (OR 1.8, 95% CI 1.3 to 2.5, p=0.0011). Compared with placebo, anifrolumab treatment was associated with earlier LLDAS attainment (time to first LLDAS, HR 1.76, 95% CI 1.35 to 2.30, p<0.0001), increased cumulative time in LLDAS (p<0.0001) and higher likelihood of sustained LLDAS (p<0.001). Anifrolumab treatment was also associated with higher rates of Definition of Remission in SLE remission at week 52 (15.3% vs 7.6%; OR 2.2, 95% CI 1.4 to 3.6, p=0.0013). CONCLUSIONS LLDAS attainment was highly associated with, but more stringent than, BICLA and SRI(4) responses. Compared with placebo, anifrolumab treatment was associated with earlier, more frequent, and more prolonged and sustained LLDAS. TRIAL REGISTRATION NUMBERS NCT02446912 and NCT02446899.
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Affiliation(s)
- Eric F Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, Victoria, Australia
| | - Gabriel Abreu
- Biometrics, Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Richard A Furie
- Division of Rheumatology, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Vera Golder
- Centre for Inflammatory Diseases, Monash University, Melbourne, Victoria, Australia
| | - Raj Tummala
- Clinical Development, Late Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland, USA
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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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8
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Raghunath S, Glikmann-Johnston Y, Golder V, Kandane-Rathnayake R, Morand EF, Stout JC, Hoi A. Clinical associations of cognitive dysfunction in systemic lupus erythematosus. Lupus Sci Med 2023; 10:10/1/e000835. [PMID: 36854540 PMCID: PMC9980376 DOI: 10.1136/lupus-2022-000835] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/10/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Cognitive dysfunction in SLE is common, but clinical risk factors are poorly understood. This study aims to explore the associations of cognitive dysfunction in SLE with disease activity, organ damage, biomarkers and medications. METHODS We performed cross-sectional cognitive assessment using a conventional neuropsychological test battery, with normative values derived from demographically matched healthy subjects. Endpoints included two binary definitions of cognitive dysfunction and seven individual cognitive domain scores. Clinical parameters included disease activity (SLEDAI-2K) and organ damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index). We performed regression analyses to determine associations between clinical parameters and cognitive endpoints. RESULTS 89 patients with SLE were studied, with median age of 45 and disease duration of 15 years. Organ damage was significantly associated with severe cognitive dysfunction (OR 1.49, CI 1.01-2.22) and worse cognitive test performance in three of the seven individual cognitive domains. In contrast, no significant associations were found between SLEDAI-2K at the time of cognitive assessment and any cognitive endpoints on multivariate analysis. Higher time-adjusted mean SLEDAI-2K was associated with better verbal memory scores but had no significant associations with other cognitive endpoints. The presence of anti-dsDNA antibodies and high IFN gene signature were negatively associated with severe cognitive dysfunction; there were no significant associations with the other autoantibodies studied or any medications. Substance use was significantly associated with lower psychomotor speed. Only 8% of patients who had cognitive dysfunction on testing had been recognised by clinicians on their SDI score. CONCLUSIONS In SLE, cognitive dysfunction was positively associated with organ damage, but not associated with disease activity, and serological activity and high IFN signature were negatively associated. Cognitive dysfunction was poorly captured by clinicians. These findings have implications for preventative strategies addressing cognitive dysfunction in SLE.
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Affiliation(s)
- Sudha Raghunath
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia .,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Yifat Glikmann-Johnston
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Vera Golder
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Rangi Kandane-Rathnayake
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
| | - Julie C Stout
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alberta Hoi
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Rheumatology Department, Monash Health, Melbourne, Victoria, Australia
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9
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Kandane-Rathnayake R, Louthrenoo W, Luo SF, Wu YJJ, Chen YH, Golder V, Lateef A, Cho J, Navarra SV, Zamora L, Hamijoyo L, Sockalingam S, An Y, Li Z, Montes R, Oon S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Chan M, Kikuchi J, Takeuchi T, Goldblatt F, O'Neill S, Bae SC, Lau CS, Hoi A, Karyekar CS, Nikpour M, Morand EF. Patterns of Medication Use in Systemic Lupus Erythematosus: A Multicenter Cohort Study. Arthritis Care Res (Hoboken) 2022; 74:2033-2041. [PMID: 34197023 DOI: 10.1002/acr.24740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Evidence for the utility of medications in settings lacking randomized trial data can come from studies of treatment persistence. The present study was undertaken to examine patterns of medication use in systemic lupus erythematosus (SLE) using data from a large multicenter longitudinal cohort. METHODS Prospectively collected data from the Asia Pacific Lupus Collaboration cohort including disease activity (SLE Disease Activity Index 2000 [SLEDAI-2K]) and medication details, captured at every visit from 2013-2018, were used. Medications were categorized as glucocorticoids (GCs), antimalarials (AM), and immunosuppressants (IS). Cox regression analyses were performed to determine the time-to-discontinuation of medications, stratified by SLE disease activity. RESULTS Data from 19,804 visits of 2,860 patients were analyzed. Eight medication categories were observed: no treatment; GC, AM, or IS only; GC plus AM; GC plus IS; AM plus IS; and GC plus AM plus IS (triple therapy). Triple therapy was the most frequent pattern (31.4% of visits); single agents were used in 21% of visits, and biologics in only 3%. Time-to-discontinuation analysis indicated that medication persistence varied widely, with the highest treatment persistence for AM and lowest for IS. Patients with a time-adjusted mean SLEDAI-2K score of ≥10 had lower discontinuation of GCs and higher discontinuation of IS. CONCLUSION Most patients received combination treatment. GC persistence was high, while IS persistence was low. Patients with high disease activity received more medication combinations but had reduced IS persistence, consistent with limited utility. These data confirm unmet need for improved SLE treatments.
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Affiliation(s)
| | | | - Shue-Fen Luo
- Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
| | | | - Yi-Hsing Chen
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - Vera Golder
- Monash University, Clayton, Victoria, Australia
| | - Aisha Lateef
- National University Hospital, Singapore, Singapore
| | - Jiacai Cho
- National University Hospital, Singapore, Singapore
| | | | - Leonid Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | | | | | - Yuan An
- People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Zhanguo Li
- People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Ricardo Montes
- Universidade do Estado Do Rio De Janeiro, Rio De Janeiro, Brazil
| | - Shereen Oon
- The University of Melbourne at St. Vincent's Hospital, Fitzroy, Victoria, Australia
| | | | | | - 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
| | - Sean O'Neill
- University of New South Wales and Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | | | - Alberta Hoi
- Monash University, Clayton, Victoria, Australia
| | - Chetan S Karyekar
- Janssen Pharmaceutical Companies of Johnson and Johnson, Horsham, Pennsylvania
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital, Fitzroy, Victoria, Australia
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10
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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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11
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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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Ko T, Koelmeyer R, Li N, Yap K, Yeo AL, Kent J, Pellicano R, Golder V, Kitching AR, Morand E, Hoi A. Predictors of infection requiring hospitalization in patients with systemic lupus erythematosus: a time-to-event analysis. Semin Arthritis Rheum 2022; 57:152099. [PMID: 36155969 DOI: 10.1016/j.semarthrit.2022.152099] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the predictors of serious infection in patients with systemic lupus erythematosus (SLE). METHODS Serious infections were identified in SLE patients in a prospectively-followed single centre cohort. Associations of serious infection with disease-related variables and medication use were analysed using Cox and related regression models. RESULTS 346 patients were followed for a mean (SD) of 6.6 (3.7) years. 86 episodes of serious infection were observed, with an incidence rate of 3.8 episodes per 100 person-years. Patients who had serious infection had higher baseline SLE Damage Index (SDI) and Charlston Comorbidity Index (CCI); they were also more likely to have high disease activity status (HDAS), and higher disease activity in multiple clinical domains, higher flare rates, higher time-adjusted prednisolone dose exposure, and less time in lupus low disease activity state (LLDAS). Patients who have received cyclophosphamide, rituximab and mycophenolate were more likely to have experienced serious infection. After multivariable adjustment in Cox regression analysis, cyclophosphamide, higher SDI score, and higher disease activity were associated with an increased hazard of first serious infection. History of previous serious infection conferred the highest risk. Lymphopenia was also a modest but statistically significant predictor of serious infection. CONCLUSION History of previous serious infection was the strongest predictor of serious infection in our SLE cohort. This study also suggests that clinical factors such as damage accrual, disease activity, and choice of immunosuppressant, can each have an independent risk in predicting serious infection particularly the first episode.
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Affiliation(s)
- Tina Ko
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Rachel Koelmeyer
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Ning Li
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Kristy Yap
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Ai Li Yeo
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Joanna Kent
- Department of Nephrology, Monash Health, Clayton VIC 3168, Australia
| | - Rebecca Pellicano
- Department of Nephrology, Monash Health, Clayton VIC 3168, Australia
| | - Vera Golder
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - A Richard Kitching
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Eric Morand
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Alberta Hoi
- Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia; Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.
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Sreedharan S, Li N, Littlejohn G, Buchanan R, Nikpour M, Morand E, Hoi A, Golder V. Association of clinic setting with quality indicator performance in systemic lupus erythematosus: a cross-sectional study. Arthritis Res Ther 2022; 24:150. [PMID: 35733186 PMCID: PMC9214991 DOI: 10.1186/s13075-022-02823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. We aimed to assess the quality of care processes in different clinic settings, comparing a subspecialty lupus clinic with hospital-based and private general rheumatology clinics. METHODS Patients with SLE (n = 258) were recruited in 2016 from a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private rheumatology clinics (n = 55). Data were collected from medical records and patient questionnaires. Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidity assessments, drug monitoring, preventative care and reproductive health. Per-QI performance was measured as a percentage of patients that met the QI relative to the number of patients eligible. Per-patient QI performance was calculated as a percentage of QIs met relative to the number of eligible QIs for each patient. Per-QI and per-patient QI performance were compared between the three clinic settings, and multiple regression performed to adjust for sociodemographic, disease and healthcare factors. RESULTS Per-QI performance was generally high across all clinic settings for diagnostic work-up, comorbidity assessment, lupus nephritis, drug monitoring, prednisolone taper, osteoporosis and pregnancy care. Median [IQR] per-patient performance on eligible QIs was higher in the subspeciality lupus clinic (66.7% [57.1-74.1]) than the hospital general rheumatology (52.7% [47.5-58.1]) and private rheumatology (50.0% [42.9-60.9]) clinics (p <0.001) and the difference remained significant after multivariable adjustment. The subspecialty lupus clinic recorded higher per-QI performance for documentation of disease activity, disease damage, cardiovascular risk factor and drug toxicity assessments, pre-immunosuppression hepatitis and tuberculosis screening, new medication counselling, vaccinations, sun avoidance education and contraception counselling. CONCLUSIONS SLE patients managed in a subspecialty lupus clinic recorded higher per-patient QI performance compared to hospital general rheumatology and private rheumatology clinics, in part related to better documentation on certain QIs.
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Affiliation(s)
- Sidha Sreedharan
- Monash University, Melbourne, Australia. .,Monash Health, Melbourne, Australia.
| | - Ning Li
- Monash University, Melbourne, Australia
| | | | | | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Eric Morand
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Alberta Hoi
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Vera Golder
- Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
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Golder V, Kandane-Rathnayake R, Louthrenoo W, Chen YH, Cho J, Lateef A, Hamijoyo L, Luo SF, Jan Wu YJ, Navarra S, Zamora L, LI Z, An Y, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Basnayake B, Chan M, Kikuchi J, Takeuchi T, Bae SC, O’neill S, Goldblatt F, Oon S, Gibson K, Ng K, Law A, Tugnet N, Kumar S, Tee C, Tee M, Tanaka Y, Lau CS, Nikpour M, Hoi A, Morand EF. OP0142 COMPARISON OF ATTAINMENT AND PROTECTIVE EFFECTS OF THE LUPUS LOW DISEASE ACTIVITY STATE IN PATIENTS WITH NEWLY DIAGNOSED VERSUS ESTABLISHED SLE - A MULTICENTRE PROSPECTIVE STUDY. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.3909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundLupus low disease activity state (LLDAS) attainment has been reported to be associated with reduced damage accrual, flare, and mortality, as well as improved quality of life, in cohorts of SLE patients with established disease. Whether these associations are present in recent-onset disease is less well known.ObjectivesTo evaluate the associations of LLDAS attainment with outcomes in patients with recent onset SLE.MethodsData from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected prospectively between 2013 and 2020 using standard templates. Organ damage and flare were captured using SLICC Damage Index and SELENA-SLEDAI Flare Index, respectively. LLDAS was defined as Golder et al., 2019 [1]. An inception cohort was defined based on duration since SLE diagnosis<1 year at enrolment. Patient characteristics between inception and non-inception cohorts were compared using Wilcoxon rank-sum (continuous variables) or Pearson’s Chi-squared tests (categorical variables). Survival analyses were performed to examine the association between LLDAS attainment and damage accrual and flare.ResultsThe study cohort included 4,106 patients of whom 680 (16%) were recruited within 1 year of SLE diagnosis (inception cohort). Compared to the non-inception cohort, inception cohort patients were significantly younger, had higher disease activity (SLEDAI-2K and physician global assessment), used more glucocorticoids and immunosuppressants but had less organ damage at enrolment and only 88 (13.6%) patients accrued damage during a median 2.2 years follow-up (Table 1).Table 1.Non-inception cohortInception cohortp-valuen=3426n=680Age at enrolment (years), median [IQR]40 [31, 51]33 [25, 44]<0.001Age at diagnosis (years), median [IQR]28 [21, 38]33 [25, 43]<0.001SLE duration at enrolment (years), median [IQR]10 [5, 16]1 [0, 1]<0.001Study duration (years), median [IQR]2.5 [1.0, 5.4]2.2 [0.9, 3.7]<0.001Females, n (%)3155 (92.1%)623 (91.6%)0.68Asian ethnicity, n (%)3037 (89.1%)595 (88.1%)0.49Prednisolone (PNL) use - ever, n (%)2865 (83.6%)620 (91.2%)<0.001Time adjusted mean (TAM)-PNL, median [IQR]5.0 [2.2, 8.6]6.2 [3.2, 10.3]<0.001Cumulative PNL (g), median [IQR]3.4 [0.5, 9.7]3.8 [1.1, 8.5]0.26Anti-Malarial use - ever, n (%)2669 (77.9%)569 (83.7%)<0.001Immunosupressant use -ever, n (%)2367 (69.1%)521 (76.6%)<0.001AMS (TAM-SLEDAI-2K), median [IQR]2.8 [1.2, 4.6]3.1 [1.6, 5.0]0.002TAM-PGA, median [IQR]0.4 [0.2, 0.7]0.4 [0.3, 0.8]<0.001Mild/moderate/severe flare ever, n (%)1789 (52.2%)391 (57.5%)0.012Organ damage accrual, n (%)629 (20.8%)88 (13.6%)<0.001LLDAS at baseline, n (%)1730 (50.5%)195 (28.7%)<0.001LLDAS-ever (at least once), n (%)2637 (78.2%)492 (73.9%)0.014≥50% time in LLDAS (LLDAS-5), n (%)1612 (50.6%)256 (41.1%)<0.001Significantly fewer inception cohort patients were in LLDAS at enrolment than the non-inception cohort (29% vs. 51%, p<0.001). However, 74% of inception and 78% of non-inception cohort patients achieved LLDAS at least once during follow-up. Limiting analysis only to patients not in LLDAS at enrolment, time to first LLDAS attainment was assessed: inception cohort patients were 60% more likely to attain their first LLDAS (HR = 1.60 (95%CI: 1.40, 1.82), p<0.001) than non-inception cohort patients. LLDAS attainment was significantly protective against flare in the inception (HR, 95% CI) and non-inception (HR, 95% CI) cohorts. Trends towards protection against damage accrual in association with LLDAS in the inception cohort were not significant.ConclusionLLDAS attainment is protective from flare in recent onset SLE. Significant protection from damage accrual was not observed, due to low rates of damage accrual in the first years after SLE diagnosis.References[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.AcknowledgementsWe thank all patients participating in the Asia Pacific Lupus Collaboration (APLC) cohort, and all data collectors for their ongoing support for APLC research activities.The APLC has received unrestricted project grants from AstraZeneca, BMS, Eli Lily, Janssen, Merck Serono, and UCB to support data collection contributing to this work.Disclosure of InterestsVera Golder: None declared, Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra and Zeneca, Sanofi, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Yes. Clinical trials and/or research grants from Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche,Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca,Astellas, Gilead, Jiacai Cho: None declared, Aisha Lateef: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson, Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Yes. Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd, Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, BMDB Basnayake: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Advisory Board member for Pfizer, Eli-Lilly, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K, Sang-Cheol Bae: None declared, Sean O’Neill Paid instructor for: Advisory board member for GSK, Fiona Goldblatt: None declared, Shereen Oon: None declared, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis – co-chair for NSW and steering committee member for ARISE meeting Feb 2021Janssen Pharmaceuticals – advisory board, Grant/research support from: Novartis, Employee of: Eli Lilly, Kristine Ng Speakers bureau: speaker fees and advisory board (Abbvie, Novartis, Janssen), Annie Law: None declared, Nicola Tugnet: None declared, Sunil Kumar: None declared, Cherica Tee: None declared, Michael Tee: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, C.S. Lau Shareholder of: Pfizer, Sanofi and Janssen, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Alberta Hoi Consultant of: AH is on the advisory board for Abbvie and GSK, Grant/research support from: AH has received research support from AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen
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Raghunath S, Guymer EK, Glikmann-Johnston Y, Golder V, Kandane Rathnayake R, Morand EF, Stout JC, Hoi A. Fibromyalgia, mood disorders, cognitive test results, cognitive symptoms and quality of life in systemic lupus erythematosus. Rheumatology (Oxford) 2022; 62:190-199. [PMID: 35383358 PMCID: PMC9788827 DOI: 10.1093/rheumatology/keac207] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Cognitive dysfunction, and comorbidities such as mood disorder and fibromyalgia, are common in SLE. This study aims to explore the associations between fibromyalgia, mood disorders, cognitive symptoms and cognitive dysfunction in SLE patients, and their impact on quality of life. METHODS We tested cognition in SLE patients and healthy controls, and evaluated cognitive symptoms, mood disorder, fibromyalgia, fatigue and quality of life using patient-reported outcome measures. We examined associations of these comorbidities with both patient-reported cognitive symptoms and cognitive test performance. RESULTS High fibromyalgia symptom score and history of depression or anxiety were associated with cognitive dysfunction. There were no significant associations between current depression, anxiety symptoms or fatigue score and objective cognitive dysfunction. In contrast, mood disorder symptoms, history of mood disorder, fibromyalgia symptoms and fatigue all had significant associations with patient-reported cognitive symptoms. There were no significant associations between patient-reported cognitive symptoms and objective cognitive dysfunction. Objective cognitive dysfunction, patient-reported cognitive symptoms, history of mood disorder and fibromyalgia symptoms all had significant associations with poorer quality of life; fibromyalgia had the biggest impact. CONCLUSIONS Cognitive symptoms are common in SLE, but there were no associations between cognitive symptoms and objective cognitive dysfunction. Depression, anxiety and fibromyalgia were more consistently associated with patient-reported cognitive symptoms than with objective cognitive dysfunction. These factors all have a significant impact on quality of life. Understanding the discrepancy between patient-reported cognitive symptoms and cognitive test performance is essential to advance care in this area of unmet need.
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Affiliation(s)
- Sudha Raghunath
- Correspondence to: Sudha Raghunath, School of Clinical Sciences, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, VIC 3168, Australia. E-mail:
| | - Emma K Guymer
- Centre for Inflammatory Disease, School of Clinical Sciences, Monash University,Rheumatology Department, Monash Health
| | - Yifat Glikmann-Johnston
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Vera Golder
- Centre for Inflammatory Disease, School of Clinical Sciences, Monash University,Rheumatology Department, Monash Health
| | | | - Eric F Morand
- Centre for Inflammatory Disease, School of Clinical Sciences, Monash University,Rheumatology Department, Monash Health
| | - Julie C Stout
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Alberta Hoi
- Centre for Inflammatory Disease, School of Clinical Sciences, Monash University,Rheumatology Department, Monash Health
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Kandane-Rathnayake R, Louthrenoo W, Golder V, Luo SF, Wu YJJ, Lateef A, Cho J, Li Z, An Y, Hamijoyo L, Navarra S, Zamora L, Katsumata Y, Harigai M, Sockalingam S, Chan M, Chen YH, O'Neill S, Goldblatt F, Hao Y, Zhang Z, Kikuchi J, Takeuchi T, Lau CS, Nikpour M, Morand E, Hoi A. Independent associations of lymphopenia and neutropenia in patients with systemic lupus erythematosus: a longitudinal, multinational study. Rheumatology (Oxford) 2021; 60:5185-5193. [PMID: 33693676 PMCID: PMC8566254 DOI: 10.1093/rheumatology/keab217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The prevalence and associations of leucopenia in SLE remain incompletely understood. We evaluated associations of disease activity and medication use with leucopenia (lymphopenia and neutropenia) in a multinational, prospectively followed SLE cohort. METHODS Data from the Asia Pacific Lupus Collaboration cohort, in which disease activity and medications were prospectively captured from 2013 to 2018, were used. Predictors of lymphopenia (lymphocyte count <0.8 × 109/l) and neutropenia (neutrophil count <1.5 × 109/l) were examined using multiple failure, time-dependent survival analyses. RESULTS Data from 2330 patients and 18 287 visits were analysed. One thousand and eighteen patients (43.7%) had at least one episode of leucopenia; 867 patients (37.2%) had lymphopenia, observed in 3065 (16.8%) visits, and 292 (12.5%) patients had neutropenia, in 622 (3.4%) visits. After multivariable analyses, lymphopenia was associated with overall disease activity, ESR, serology, prednisolone, AZA, MTX, tacrolimus, CYC and rituximab use. MTX and ciclosporin were negatively associated with neutropenia. Lupus low disease activity state was negatively associated with both lymphopenia and neutropenia. CONCLUSION Both lymphopenia and neutropenia were common in SLE patients but were differentially associated with disease and treatment variables. Lymphopenia and neutropenia should be considered independently in studies in SLE.
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Affiliation(s)
- Rangi Kandane-Rathnayake
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Worawit Louthrenoo
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University Hospital, Thailand
| | - Vera Golder
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shue-Fen Luo
- Chang Gung Memorial Hospital, Rheumatology, Allergy and Immunology, Taipei and Keelung, Taiwan
| | - Yeong-Jian J Wu
- Chang Gung Memorial Hospital, Rheumatology, Allergy and Immunology, Taipei and Keelung, Taiwan
| | - Aisha Lateef
- National University Hospital, University Medicine Cluster, Singapore, Singapore
| | - Jiacai Cho
- National University Hospital, University Medicine Cluster, Singapore, Singapore
| | - 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
| | - Laniyati Hamijoyo
- Division of Rheumatology, Padjadjaran University/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Madelynn Chan
- Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sean O'Neill
- Liverpool Hospital and the Ingham Institute for Applied Medical Research, Rheumatology, Liverpool, NSW
| | - Fiona Goldblatt
- Department of Rheumatology, Royal Adelaide Hospital
- Flinders Medical Centre, Department of Rheumatology, Adelaide, South Australia, Australia
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - 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
| | - Chak Sing Lau
- The University of Hong Kong, Medicine, Hong Kong, Hong Kong
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital, Medicine and Rheumatology, Melbourne, Victoria, Australia
| | - Eric Morand
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alberta Hoi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Connelly K, Vettivel J, Golder V, Kandane-Rathnayake R, Morand EF. Measurement of specific organ domains in lupus randomised controlled trials: a scoping review. Rheumatology (Oxford) 2021; 61:1341-1353. [PMID: 34664636 DOI: 10.1093/rheumatology/keab777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Randomised controlled trials (RCTs) in systemic lupus erythematosus (SLE, lupus) typically adopt composite responder definitions as primary efficacy endpoints, however outcomes within individual organ domains are also important to understand. The aim of this scoping review was to evaluate how organ-specific disease activity and therapeutic responses have been measured and reported in lupus RCTs. METHODS We searched MEDLINE, EMBASE, Cochrane registry and clinicaltrials.gov. Eligible studies were RCTs investigating efficacy of an immune-directed drug therapy in active SLE, published January 2000-March 2021, excluding studies limited to lupus nephritis. Data were extracted independently in duplicate into a template and summarised descriptively. RESULTS Thirty-four RCTs were included, of which 32 (94%) reported activity and/or responses in at least one organ domain. Study populations had a high, although variable, frequency of baseline musculoskeletal and mucocutaneous activity and low but also variable representation of other domains. Definitions of organ-specific responses were inconsistent, even within individual instruments. Response in most organ domains were evaluated using BILAG and SLEDAI components but meaningful comparison between treatment arms was limited by small subgroups analysed in a post hoc fashion. Specific mucocutaneous and arthritis instruments were also used, including within pre-specified organ-specific endpoints, which discriminated between treatment arms in some studies. CONCLUSION Mucocutaneous and musculoskeletal manifestations predominate in SLE RCTs. Organ-specific outcome measures are commonly reported, but definitions of involvement and response are inconsistent. Research into the development of new outcome measures for key organ domains, and validation and comparison of response definitions using existing instruments, is needed.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | - Jeevan Vettivel
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia
| | - Vera Golder
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
| | | | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton VIC 3168, Australia.,Department of Rheumatology, Monash Health, Clayton VIC 3168, Australia
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Connelly K, Golder V, Kandane-Rathnayake R, Morand EF. Clinician-reported outcome measures in lupus trials: a problem worth solving. Lancet Rheumatol 2021; 3:e595-e603. [PMID: 38287623 DOI: 10.1016/s2665-9913(21)00119-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 02/08/2023]
Abstract
Systemic lupus erythematosus (SLE) remains a disease of high unmet clinical need. Because of substantial patient heterogeneity, the execution of clinical trials that successfully determine the efficacy of novel therapeutics compared with placebo is a continuous challenge. Clinician-reported outcome measures of treatment response used in SLE trials have evolved from the use of individual disease activity indices, including the SLE Disease Activity Index (SLEDAI) and British Isles Lupus Assessment Group (BILAG), to composite responder definitions such as the SLE Responder Index (SRI) and BILAG-Based Composite Lupus Assessment (BICLA), which are based on these indices. However, these approaches have notable drawbacks and defining the optimal clinical trial outcome measure for SLE remains a research goal. In this Viewpoint, we explore the strengths and limitations of existing indices and composite assessments, illustrating features which should be investigated in future analysis of trial data. Further, we provide a platform from which to advance new approaches to endpoint design, which is crucial to improve the interpretability and success of subsequent clinical trials in SLE.
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Affiliation(s)
- Kathryn Connelly
- School of Clinical Sciences, Monash University, Clayton, VIC 3168, Australia; Department of Rheumatology, Monash Health, Monash University, Clayton, VIC 3168, Australia
| | - Vera Golder
- School of Clinical Sciences, Monash University, Clayton, VIC 3168, Australia; Department of Rheumatology, Monash Health, Monash University, Clayton, VIC 3168, Australia
| | | | - Eric F Morand
- School of Clinical Sciences, Monash University, Clayton, VIC 3168, Australia; Department of Rheumatology, Monash Health, Monash University, Clayton, VIC 3168, Australia.
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Raghunath S, Golder V, Kandane-Rathnayake R, Morand EF, Glikmann-Johnston Y, Stout JC, Hoi A. POS0731 CLINICAL ASSOCIATIONS OF COGNITIVE DYSFUNCTION IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE). Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.1487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Cognitive symptoms are commonly reported by SLE patients, but the prevalence and clinical associations of cognitive dysfunction (CD) is poorly understood.Objectives:To examine the relationship between SLE disease parameters and CD.Methods:Patients with SLE were consecutively recruited from 2018-2020. Cognitive assessment was performed using the one-hour conventional neuropsychiatric test battery recommended by the American College of Rheumatology for SLE1. Three binary definitions of CD and seven cognitive test z-scores were included in analysis. Clinical parameters included disease activity (SLEDAI-2K) and damage (SDI). Multivariate regression analysis was performed to determine associations with cognitive endpoints using variables with p <0.1 on univariate testing; likelihood ratio tests were used to select for inclusion from collinear pairs. A subgroup univariate analysis was performed to look for associations with interferon gene signature (IGS) and metabolic indices.Results:91 SLE patients and 48 age, sex, and premorbid IQ matched controls were recruited. The median (range) age was 45 (21-64) and median disease duration 13 years (0.2-39). 60% were Caucasian and the rest predominantly Asian, and all had good English proficiency. Prevalence of CD varied based on definition used; 18% had ≥2 cognitive domains ≥2 SD below the healthy control mean, whereas 48% were considered impaired if this threshold was reduced to ≥1.5 SD below. Age and premorbid IQ were significantly associated with multiple cognitive endpoints, and SDI was associated with four endpoints including the most severe definition of CD. Increased parity and past strokes correlated with poorer cognition in two endpoints. In contrast, clinical variables such as SLEDAI, antiphospholipid antibodies and past seizures only correlated with one endpoint each. There were no associations with other antibodies or any medications including glucocorticoids. Subgroup analysis showed univariate associations of CD with increased waist circumference, hypertriglyceridemia and low IGS.Conclusion:Clinical associations of CD in SLE vary according to the cognitive domain or impairment definition used. SDI was the disease-related factor most consistently associated with CD, while IGS was negatively and metabolic features positively associated with CD. Studies of CD in SLE should use standardised methods to determine CD.References:[1]Liang et al. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999;42(4).Table 1.Multivariate Analysis of Clinical Predictors of Cognitive Dysfunction in SLECognitive Dysfunction Definitions1Individual Cognitive Domains (Tests)2 domains-1.5 SD1 domain-2 SD2 domains-2 SDVisual Memory(ROCF recall)Verbal Memory(CVLT 1-5)Verbal Fluency(COWAT FAS)Working Memory(LNS score)Processing Speed(Coding score)Complex attention(TMT B time)Psychomotor Speed(Finger tap)Odds ratio(logistic regression)Coefficient (linear regression)Age1.06*1.06*-0.03*-0.014*-0.03**Premorbid IQ0.89**0.86**0.85*0.056**0.044**0.072**0.028**0.026*0.05**0.017SLEDAI0.860.89Time-adjusted mean SLEDAI0.14**-0.012PGA0.79**0.44SDI1.91*-0.25**-0.15**-0.22**Past stroke or TIA7.9413.19*-0.97**Past seizures-0.65*-0.24Methotrexate-0.23Anti Ro0.22Anti-cardiolipin0.38*Any APLS abs0.037**Parity2.21**-0.05-0.051-0.22**Substance use2.58-0.49*-0.62*1Impairment defined by number of cognitive domains either 1.5 or 2 SD below healthy control group mean*p value <0.05 **p value <0.005 Abbreviations: SLEDAI - SLE Disease Activity Index, PGA - Physician global assessment, SDI - SLE International Collaborating Clinics Damage Index, TIA - Transient Ischaemic Attack, abs - Antibodies, APLS - Antiphospholipid Syndrome, ROCF - Rey-Ostrrieth Complex Figure Test, CVLT - California Verbal Learning Test, COWAT - Controlled Oral Word Association Test, LNS and Coding - Letter Number Sequencing & Coding subsets of Wechsler Adult Intelligence Scale IV, TMT - Trail Making TestAcknowledgements:We would like to acknowledge the patients who contribute to the Australian Lupus Registry and Biobank (ALRB) and participated in this study. The ALRB has received sponsorship from AstraZeneca, UCB and Arthritis Victoria.Disclosure of Interests:None declared
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Sreedharan S, Hoi A, Li N, Littlejohn G, Buchanan R, Nikpour M, Morand EF, Golder V. POS0753 SUBSPECIALTY LUPUS CLINIC CARE IS ASSOCIATED WITH HIGHER QUALITY FOR PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. Disease-specific subspecialty clinics offer experienced healthcare professionals, collaborative multidisciplinary teams and streamlined care processes. A single centre study in the USA has suggested superior performance of the subspecialty lupus clinic in the provision of quality care (1), but this has not been examined outside the USA where access to care may be influential.Objectives:To assess the quality of SLE care provided in a subspecialty lupus clinic compared with hospital general rheumatology and private rheumatology clinics in a non-US, universal healthcare setting.Methods:Lupus patients (n = 258) were recruited in 2016 from various clinic settings in Australia, including a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private clinics (n = 55). Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidities assessment, drug monitoring, preventative care and reproductive health (2,3). Data were collected from medical records and patient questionnaires. Overall and individual QI performance was calculated and compared between the three clinic settings, and multivariable regression was performed to adjust for sociodemographic, disease and healthcare factors.Results:Median [IQR] overall performance on eligible QIs was higher in the lupus clinic (66.7% [16.9]) than the hospital general rheumatology (52.7% [10.6]) and private rheumatology (50.00% [18.0]) clinics (p <0.01), and remained significant with multivariable adjustment. This trend was still observed when the overall performance was reassessed to include patient self-report (73.1% [14.8] vs 68.1% [11.5] vs 63.2% [13.4], p <0.01). This difference may be due to consistent formal assessments of disease activity (100% vs 0% vs 0%, p <0.01) and disease damage (95.9% vs 0% vs 0%, p <0.01) at the lupus clinic. Performance was high across all clinic settings for diagnostic work-up, comorbidity assessment, drug monitoring, prednisolone taper, osteoporosis management, lupus nephritis and pregnancy quality indicators. However, the lupus clinic significantly outperformed the other clinic settings on eligible quality indicators for new medication counselling, pre-immunosuppression hepatitis and tuberculosis screening, drug toxicity assessment, sun avoidance education, vaccinations, cardiovascular risk factor assessment and contraception counselling.Conclusion:SLE patients managed in a subspecialty lupus clinic received higher overall quality of care when compared to hospital general rheumatology and private rheumatology clinics. Regular assessment of QI performance can improve quality of care for patients in all clinic settings.References:[1]Arora, S et al. Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic? Arthritis Care Res. 2018;70(12):1771-1777.[2]Mosca, M et al. Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice. Autoimmune Rev. 2011;10(7):383-8.[3]Yazdany, J et al. A quality indicator set for systemic lupus erythematosus. Arthritis Rheum. 2009;61(3):370-7.Disclosure of Interests:None declared
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Kandane-Rathnayake R, Louthrenoo W, Hoi A, Golder V, Chen YH, Luo SF, Jan Wu YJ, Lateef A, Cho J, Hamijoyo L, Lau CS, Navarra S, Zamora L, LI Z, An Y, Sockalingam S, Katsumata Y, Harigai M, Hao Y, Zhang Z, Kikuchi J, Takeuchi T, Basnayake B, Goldblatt F, Chan M, Ng K, Bae SC, Oon S, O’neill S, Gibson K, Kumar S, Tugnet N, Tanaka Y, Nikpour M, Morand EF. POS0028 DEFINING THE PREVALENCE OF UNMET NEED IN SLE: DATA FROM A LARGE MULTINATIONAL LONGITUDINAL SLE COHORT. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:The recent prospectively validated definition of the lupus low disease activity state (LLDAS) allows characterisation of patients not achieving a treatment goal, providing impetus for an analysis of unmet needs in SLE using formal definitions. Other recently described definitions of high disease burden include disease activity over time, high disease activity status (HDAS) episodes, and the combination of high disease activity, serological activity and glucocorticoid (GC) use (HDAS+SA+GC).Objectives:To determine the prevalence of formal categories of unmet need, and the association of these with adverse outcomes, in SLE.Methods:Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected between 2013 and 19 using standard templates. Unmet need was defined as (i) patients never attaining LLDAS defined as in Golder et al., 2019 [1], (ii) having persistently active disease (time adjusted mean SLEDAI-2K (AMS) > 4), (iii) ever exhibiting high disease activity status (HDAS; SLEDAI-2K ≥10[2]), or (iv) ever exhibiting all of SLEDAI≥10, serological activity, and glucocorticoid use (HDAS+SA+GC)[3]. Health-related quality of life (HRQoL) was assessed using SF36 (v2) surveys and damage accrual using SLE Damage Index (SDI).Results:3,384 SLE patients were followed for 30,313 visits over median [IQR] 2.4 [0.4, 4.3] years. 53% of all visits were not in LLDAS; 813 patients (24%) never achieved LLDAS during observation. Median AMS was 3.0 [1.4, 4.9] and 34% of patients had AMS > 4 throughout the study. 25% of patients had at least one episode of HDAS, representing 8% of visits. 702 patients (21%) had at least one episode of HDAS+SA+GC, representing 8% of visits. Each of never-LLDAS, AMS>4, ever-HDAS, and ever-HDAS+SA+GC were associated with significantly greater number of physician visits, higher mean glucocorticoid dose, lower HRQoL and higher mortality. 31%, 58% and 83% of never-LLDAS, AMS>4, and ever-HDAS patients respectively were also HDAS+SA+GC on at least one occasion.Conclusion:Data from a multinational longitudinal SLE cohort indicate that unmet need, defined by LLDAS-never, AMS>4, HDAS, or HDAS+SA+GC, is prevalent in SLE, and that these definitions are associated with poor outcomes.References:[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.[2]Koelmeyer, R., et al., High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med, 2020. 7(1).[3]van Vollenhoven, R.F., et al., Belimumab in the treatment of systemic lupus erythematosus: high disease activity predictors of response. Annals of the Rheumatic Diseases, 2012. 71(8): p. 1343-1349.Acknowledgements:The APLC acknowledges all the Data Collectors and Patients for their valuable contributions to research.Disclosure of Interests:Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Alberta Hoi Consultant of: Abbvie and GSK, Grant/research support from: AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Vera Golder: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche, Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca, Astellas, Gilead, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Aisha Lateef: None declared, Jiacai Cho: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Chak Sing Lau Shareholder of: Pfizer, Sanofi, and Janssen, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson., Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., masayoshi harigai Speakers bureau: AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie, Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K., BMDB Basnayake: None declared, Fiona Goldblatt: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Pfizer, Eli-Lilly, Kristine Ng Speakers bureau: Abbvie, Novartis, Janssen, Sang-Cheol Bae: None declared, Shereen Oon: None declared, Sean O’Neill Consultant of: GSK, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis, Janssen, Grant/research support from: Novartis, Sunil Kumar: None declared, Nicola Tugnet: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen.
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Abstract
Treat-to-target strategies have changed the approach to management of many chronic conditions, with improvements in patient outcomes. The key to success of treat to target is the availability of validated treatment endpoints, which have been difficult to derive for SLE, a condition notorious for its heterogeneity. This review will focus on the development and validation of the definitions of remission in SLE framework and the lupus low disease activity state. Lupus low disease activity state is more attainable than remission, with a stepwise concentric relationship between the target states indicating increasing stringency. Both lupus low disease activity state and definitions of remission in SLE remission have been proven to be associated with reduction in disease flares, reduced risk of accrual of irreversible end organ damage, and improvement in patient reported outcomes. These endpoints have therefore provided the key for the development of a treat-to-target approach in clinical practice in SLE and for the design of future clinical trials.
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Affiliation(s)
- Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Michel W P Tsang-A-Sjoe
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands
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Yeo AL, Koelmeyer R, Kandane‐Rathnayake R, Golder V, Hoi A, Huq M, Hammond E, Nab H, Nikpour M, Morand EF. Lupus Low Disease Activity State and Reduced Direct Health Care Costs in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 72:1289-1295. [DOI: 10.1002/acr.24023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 07/02/2019] [Indexed: 01/30/2023]
Affiliation(s)
- Ai Li Yeo
- Monash University and Monash Health Clayton Victoria Australia
| | | | | | - Vera Golder
- Monash University and Monash Health Clayton Victoria Australia
| | - Alberta Hoi
- Monash University and Monash Health Clayton Victoria Australia
| | - Molla Huq
- University of Melbourne, Parkville, Monash University, Clayton, and St Vincent’s Hospital Melbourne Fitzroy Victoria Australia
| | - Edward Hammond
- AstraZeneca, Gaithersburg, Maryland, and AstraZeneca Cambridge UK
| | - Henk Nab
- AstraZeneca, Gaithersburg, Maryland, and AstraZeneca Cambridge UK
| | - Mandana Nikpour
- University of Melbourne, Parkville, and St Vincent’s Hospital Melbourne Fitzroy Victoria Australia
| | - Eric F. Morand
- Monash University and Monash Health Clayton Victoria Australia
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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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Kandane-Rathnayake R, Louthrenoo W, Luo SF, Wu YJ, Chen YH, Golder V, Lateef A, Cho J, Navarra S, Zamora L, Hamijoyo L, Sockalingam S, An Y, Li Z, Katsumata Y, Harigai M, Hao Y, Zhang Z, Chan M, Kikuchi J, Takeuchi T, Goldblatt F, O’neill S, Karyekar C, Lofland JH, Bae SC, Lau CS, Hoi A, Nikpour M, Morand EF. AB0384 MEDICATION USE IN SYSTEMIC LUPUS ERYTHEMATOSUS – DATA FROM A MULTICENTRE COHORT STUDY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:In the absence of evidence-based treatment guidelines, medication use in SLE is highly variable. Low rates of remission and lupus low disease activity state (LLDAS) suggest that suboptimal responses to standard medications, which include glucocorticoids (GC), anti-malarial (AM) drugs and immunosuppressive (IS) agents, are common. Understanding the utility of current medications will facilitate the selection of patients for advanced therapies as they emerge.Objectives:To examine medication use patterns in a large multicentre SLE cohort.Methods:We used 2013-18 data from the Asia Pacific Lupus Collaboration (APLC) cohort in which disease activity (SLEDAI-2K) and medication details were captured at every visit. LLDAS was defined as in Golderet al., 2019 (1). We examined the use of medication (med) categories (GC &/or AM &/or IS) by SLE disease activity and LLDAS at the visit level. Additionally, we performed Cox regression analyses to determine the time-to-discontinuation of meds stratified by SLE disease activity, ranked by time-adjusted mean SLEDAI-2K, and by percent-time spent in LLDAS.Results:We analysed data from 19,804 visits of 2,860 patients. We observed 8 med categories: no meds; GC, AM or IS only; GC+AM; GC+IS; AM+IS and GC+AM+IS (triple therapy). Triple therapy was the most frequent med pattern (32%); single agents were used in 21% of visits and biologicals in only 3%. Among visits where SLEDAI-2K was ≥10, triple therapy was used in 46%, with median [IQR] GC dose 10 [6, 24] mg/day; in contrast, among visits with SLEDAI-2K≤4 triple therapy was used in 28% (p<0.01). Patients in LLDAS received less combination therapy than those who were not in LLDAS.Med persistence (survival analysis) varied widely, with lowest survivals for IS. Patients with time-adjusted mean SLEDAI-2K ≥10 had lower discontinuation of GC and higher discontinuation of IS including azathioprine, leflunomide and cyclosporine (Table 1). In contrast, increased time in LLDAS was associated with reduced discontinuation of AM and azathioprine.GCAMISMPhMPhAAZAMTXCyALEFOverall med survival, days to 25% discontinuation (95%CI)1048(938, 1197)1267(1113, 1428)175(175, 182)387(252, 756)409(350, 476)525(219, 686)268(182, 350)329(190, 524)Univariable associations,HR (95% CI) p-valueDisease activity≤41.001.001.001.001.001.001.001.00>4 & <100.69 (0.56,0.84)p<0.0011.15 (0.92,1.44)0.20.92 (0.80,1.05)0.21.37 (0.78,2.42)0.31.16 (0.97,1.39)0.111.11 (0.72,1.71)0.61.26 (0.90,1.77) 0.181.88 (1.07,3.30) 0.03≥100.65 (0.35,1.21) 0.181.56 (0.94,2.59) 0.080.84 (0.45,1.57)0.61.92 (0.80,4.63)0.142.69 (1.86,3.91) p<0.0011.85 (0.92,3.71) 0.082.66 (1.36,5.21) 0.0041.62 (1.13,2.32)0.009LLDAS<50%1.001.001.001.001.001.001.001.00≥50%1.30 (1.09, 1.55)0.0030.67 (0.54, 0.84)<0.0011.22 (1.08, 1.40)0.0020.83 (0.44,1.57)0.60.83 (0.69, 1.00)0.0540.70 (0.46, 1.07)0.101.29 (0.92, 1.83)0.140.43 (1.5, 1.25)0.12Conclusion:In a large multicentre SLE cohort, most patients were receiving combination treatment. AM treatment survival was high and associated with low disease activity, GC survival was high and associated with high disease activity, while IS survival was low. Patients with high disease activity received more medication combinations but had reduced IS survival. These data suggest ongoing unmet need for improved medications for treatment of SLE.Reference:Golder, V., et al Lancet Rheum. 2019 1(2):e95-102Disclosure of Interests:Rangi Kandane-Rathnayake Grant/research support from: The APLC has received financial (non-restricted educational) grants from AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Janssen, EMD Serono, Eli Lilly and UCB for the LLDAS Validation Study., Worawit Louthrenoo: None declared, Shue Fen Luo: None declared, Yeong-Jian Wu Consultant of: Pfizer, Lilly, Novartis, Abbvie, Roche, Speakers bureau: Lilly, Novartis, Yi-Hsing Chen Grant/research support from: Taiwan Ministry of Science and Technology, Taiwan Department of Health, Taichung Veterans General Hospital, National Yang-Ming University, GSK, Pfizer, BMS., Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Paid instructor for: Pfizer, Novartis, Johnson & Johnson, Roche, Lilly, Astra& Zeneca, Sanofi, Astellas, Agnitio Science Technology, United Biopharma., Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Vera Golder: None declared, Aisha Lateef: None declared, Jiacai Cho: None declared, Sandra Navarra Speakers bureau: Astellas, Novartis, Pfizer, Johnson & Johnson, Abbvie, Leonid Zamora: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Tanabe, Abbot, Dexa Medica, Roche, Sargunan Sockalingam: None declared, Yuan An: None declared, Zhanguo Li: None declared, Yasuhiro Katsumata: None declared, masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma., Yanjie Hao: None declared, Zhuoli Zhang: None declared, Madelynn Chan: None declared, Jun Kikuchi: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Fiona Goldblatt: None declared, Sean O’Neill: None declared, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Jennifer H. Lofland Employee of: Janssen, Sang-Cheol Bae: None declared, Chak Sing Lau: None declared, Alberta Hoi: None declared, Mandana Nikpour: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca
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Apostolopoulos D, Kandane-Rathnayake R, Louthrenoo W, Luo SF, Wu YJ, Lateef A, Golder V, Sockalingam S, Navarra S, Zamora L, Hamijoyo L, Katsumata Y, Harigai M, Chan M, O'Neill S, Goldblatt F, Lau CS, Li ZG, Hoi A, Nikpour M, Morand E. Factors associated with damage accrual in patients with systemic lupus erythematosus with no clinical or serological disease activity: a multicentre cohort study. Lancet Rheumatol 2020; 2:e24-e30. [PMID: 38258272 DOI: 10.1016/s2665-9913(19)30105-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evaluating the contribution of glucocorticoid use to organ damage in systemic lupus erythematosus is confounded by glucocorticoid use in active disease. We sought to determine the independence of the contribution of glucocorticoid use to damage accrual from associations with disease activity by analysing patients without measurable disease activity. METHODS Patients (age >18 years) who met the criteria for systemic lupus erythematosus were recruited from 13 centres in Australia, Indonesia, Japan, Malaysia, the Philippines, Singapore, Taiwan, and Thailand, and followed longitudinally. Disease activity (Systemic Lupus Erythematosus Disease Activity Index 2000 [SLEDAI-2K] and Physician Global Assessment [PGA] scores) and treatment details were recorded at each visit (at least once every 6 months), and organ damage measured annually according to the Systemic Lupus International Collaborating Clinics Damage Index (SDI). Glucocorticoid use during the study period was recorded as any exposure to prednisolone, cumulative prednisolone exposure, and time-adjusted mean daily prednisolone dose. Multivariate survival analyses were used to examine time-dependent associations of glucocorticoid use with damage accrual (defined as an increase of ≥1 on SDI). A SLEDAI-2K score of 0 was taken to indicate the absence of clinical and serological disease activity; a subset of patients without disease activity during the study were defined by a time-adjusted mean SLEDAI-2K (AMS) score of 0. FINDINGS Between May 1, 2013, and Dec 31, 2016, 1707 patients were recruited. Over a median observation period of 2·2 years (IQR 1·5-3·0), damage accrual events were observed in 255 (14·9%) patients. 1405 (82·3%) of patients were exposed to prednisolone, with a median time-adjusted mean prednisolone dose of 5·0 mg/day (IQR 1·9-8·8). As SLEDAI-2K and PGA scores were highly correlated, two multivariable models were set, each including one of these two variables. In the model including AMS score, baseline SDI damage (SDI >0) was independently associated with damage accrual (HR 1·32 [95% CI 1·01-1·73], p=0·0427). In the other model, time-adjusted mean PGA score was independently associated with damage accrual (1·05 [1·02-1·08], p=0·0012). In both models, factors independently associated with damage accrual included time-adjusted mean prednisolone dose, age at enrolment, and ethnicity (Asian vs non-Asians). 157 (9·2%) patients had an AMS score of 0 (no disease activity), among whom 103 (65·6%) had glucocorticoid exposure and the median time-adjusted mean prednisolone dose was 2·0 mg/day (IQR 0·0-5·0). Accrual of irreversible organ damage occurred in 21 (13·4%) of these patients and was independently associated with time-adjusted mean prednisolone dose (HR 1·14 [95% CI 1·03-1·26], p=0·0117), time-adjusted mean PGA score (1·13 [1·03-1·23], p=0·0144), and age at enrolment (1·04 [1·01-1·07], p=0·0061), but not baseline SDI damage (0·94 [0·43-2·06], p=0·8675). INTERPRETATION Glucocorticoid use contributes to damage accrual in systemic lupus erythematosus independently of the presence of clinical or serological disease activity. FUNDING UCB Pharma, GlaxoSmithKline, Janssen, Bristol-Myers Squibb, and AstraZeneca (to the Asia-Pacific Lupus Collaboration).
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Affiliation(s)
| | | | - Worawit Louthrenoo
- Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yeong-Jian Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Aisha Lateef
- Rheumatology Division, National University Hospital, Singapore
| | - Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | | | - Sandra Navarra
- Joint and Bone Centre, University of Santo Tomas Hospital, Manila, Philippines
| | - Leonid Zamora
- Joint and Bone Centre, University of Santo Tomas Hospital, Manila, Philippines
| | - Laniyati Hamijoyo
- Department of Internal Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Sean O'Neill
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Fiona Goldblatt
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Rheumatology, Flinders Medical Centre, Adelaide, SA, Australia
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zhan Guo Li
- Department of Rheumatology and Immunology, People's Hospital, Peking University Health Sciences Centre, Beijing, China
| | - Alberta Hoi
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Mandy Nikpour
- Department of Rheumatology, The University of Melbourne, Melbourne, VIC, Australia
| | - Eric Morand
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
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Kandane-Rathnayake R, Kent JR, Louthrenoo W, Luo SF, Wu YJJ, Lateef A, Golder V, Sockalingam S, Navarra SA, Zamora L, Hamijoyo L, Katsumata Y, Harigai M, Chan M, O’Neill S, Goldblatt F, Lau CS, Hoi A, Nikpour M, Morand E. Longitudinal associations of active renal disease with irreversible organ damage accrual in systemic lupus erythematosus. Lupus 2019; 28:1669-1677. [DOI: 10.1177/0961203319887799] [Citation(s) in RCA: 5] [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] [Indexed: 12/17/2022]
Abstract
Objective To examine longitudinal associations of active lupus nephritis with organ damage accrual in patients with systemic lupus erythematosus (SLE). Methods This study was performed using data from a large multinational prospective cohort. Active lupus nephritis at any visit was defined by the presence of urinary casts, proteinuria, haematuria or pyuria, as indicated by the cut-offs in the SLE Disease Activity Index (SLEDAI)-2K, collected at each visit. Organ damage accrual was defined as a change of SLICC-ACR Damage Index (SDI) score >0 units between baseline and final annual visits. Renal damage accrual was defined if there was new damage recorded in renal SDI domains (estimated glomerular filtration rate <50%/proteinuria >3.5 g per 24 h/end-stage kidney disease). Time-dependent hazard regression analyses were used to examine the associations between active lupus nephritis and damage accrual. Results Patients ( N = 1735) were studied during 12,717 visits for a median (inter-quartile range) follow-up period of 795 (532, 1087) days. Forty per cent of patients had evidence of active lupus nephritis at least once during the study period, and active lupus nephritis was observed in 3030 (24%) visits. Forty-eight per cent of patients had organ damage at baseline and 14% accrued organ damage. Patients with active lupus nephritis were 52% more likely to accrue any organ damage compared with those without active lupus nephritis (adjusted hazard ratio = 1.52 (95% confidence interval (CI): 1.16, 1.97), p < 0.02). Active lupus nephritis was strongly associated with damage accrual in renal but not in non-renal organ domains (hazard ratios = 13.0 (95% CI: 6.58, 25.5) p < 0.001 and 0.96 (95% CI: 0.69, 1.32) p = 0.8, respectively). There was no effect of ethnicity on renal damage accrual, but Asian ethnicity was significantly associated with reduced non-renal damage accrual. Conclusion Active lupus nephritis measured using the SLEDAI-2K domain cut-offs is associated with renal, but not non-renal, damage accrual in SLE.
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Affiliation(s)
- R Kandane-Rathnayake
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - J R Kent
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
- Department of Nephrology, Monash Health, Clayton, Australia
| | | | - S -F Luo
- Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
| | - Y -JJ Wu
- Chang Gung Memorial Hospital, Taipei and Keelung, Taiwan
| | - A Lateef
- National University Hospital, Singapore
| | - V Golder
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | | | - S a Navarra
- University of Santo Tomas Hospital, Manila, Philippines
| | - L Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | - L Hamijoyo
- University of Padjadjaran, Bandung, Indonesia
| | | | - M Harigai
- Tokyo Women’s Medical University, Japan
| | - M Chan
- Tan Tock Seng Hospital, Singapore
| | - S O’Neill
- Rheumatology Liverpool Hospital, SWS Clinical School, UNSW and the Ingham Institute for Applied Medical Research, Sydney, Australia
| | - F Goldblatt
- Royal Adelaide Hospital, Adelaide, Australia
- Flinders Medical Centre, Adelaide, Australia
| | - C S Lau
- The University of Hong Kong, Hong Kong
| | - A Hoi
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - M Nikpour
- St. Vincent’s Hospital, Melbourne, Australia
| | - E Morand
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Morand EF, Golder V. Defining remission in systemic lupus erythematosus: still elusive? Lancet Rheumatol 2019; 1:e137-e138. [PMID: 38229386 DOI: 10.1016/s2665-9913(19)30065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 01/18/2024]
Affiliation(s)
- Eric F Morand
- Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, VIC 3168, Australia.
| | - Vera Golder
- Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, VIC 3168, Australia
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Golder V, Kandane-Rathnayake R, Huq M, Nim HT, Louthrenoo W, Luo SF, Wu YJJ, Lateef A, Sockalingam S, Navarra SV, Zamora L, Hamijoyo L, Katsumata Y, Harigai M, Chan M, O'Neill S, Goldblatt F, Lau CS, Li ZG, Hoi A, Nikpour M, Morand EF. Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. Lancet Rheumatol 2019; 1:e95-e102. [PMID: 38229349 DOI: 10.1016/s2665-9913(19)30037-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treat-to-target strategies have improved outcomes in single-organ diseases with simple clinical or laboratory endpoints. A lack of validated endpoints has prevented adoption of treat to target for complex multiorgan conditions, such as systemic lupus erythematosus (SLE). We report the first prospective study undertaken to specifically validate a treat-to-target endpoint for SLE. METHODS In this prospective cohort study, patients aged 18 years or older with SLE were recruited from 13 centres in eight countries and followed prospectively. Patients with at least two visits over the study period no more than 6 months apart were included in the longitudinal analysis. Patients with no visits in the final year of the study were censored from their last visit. Attainment of the lupus low disease activity state (LLDAS) was assessed at each visit. The primary outcome measure was accrual of irreversible end-organ damage, defined as at least a 1-point increase in the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index. We used time-dependent hazard regression models and generalised linear models to measure the association between LLDAS (attainment at any timepoint, cumulative time in LLDAS, and sustained LLDAS) with accrual of irreversible end-organ damage or flare (key secondary outcome). This study is registered with ClinicalTrials.gov, NCT03138941. FINDINGS Between May 1, 2013, and Dec 31, 2016, 1707 patients were recruited and followed for a mean of 2·2 years (SD 0·9), totalling 12 689 visits. Attainment of LLDAS at any timepoint was associated with reduction in damage accrual (hazard ratio 0·59, 0·45-0·76; p<0·0001) and subsequent flare (0·65, 95% CI 0·56-0·75; p<0·0001). Cumulative time in LLDAS was associated with improved outcomes: compared with patients with less than 50% of observed time in LLDAS, those with at least 50% of observed time in LLDAS had reduced risk of damage accrual (0·54, 0·42-0·70; p<0·0001) and flare (0·41, 0·35-0·48; p<0·0001). Similarly, increased durations of sustained LLDAS were associated with incremental reductions in the risk of damage accrual. The association of LLDAS with reduced damage accrual was observed regardless of pre-existing damage or disease activity at study entry. INTERPRETATION LLDAS attainment is associated with significant protection against flare and damage accrual in SLE. These findings validate LLDAS as an endpoint for clinical studies in SLE. FUNDING The Asia Pacific Lupus Collaboration received project support grants from UCB Pharma, GlaxoSmithKline, Janssen, Bristol-Myers Squibb, and AstraZeneca.
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Affiliation(s)
- Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
| | | | - Molla Huq
- Department of Rheumatology, The University of Melbourne, Melbourne, VIC, Australia
| | - Hieu T Nim
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Worawit Louthrenoo
- Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Yeong-Jian Jan Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Aisha Lateef
- Rheumatology Division, National University Hospital, Singapore
| | | | - 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
| | - Laniyati Hamijoyo
- Department of Internal Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Madelynn Chan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Sean O'Neill
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Fiona Goldblatt
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Rheumatology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zhan Guo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Alberta Hoi
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Mandana Nikpour
- Department of Rheumatology, The University of Melbourne, Melbourne, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
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Golder V, Kandane-Rathnayake R, Huq M, Louthrenoo W, Luo SF, Wu YJJ, Lateef A, Sockalingam S, Navarra SV, Zamora L, Hamijoyo L, Katsumata Y, Harigai M, Chan M, O'Neill S, Goldblatt F, Lau CS, Li ZG, Hoi A, Nikpour M, Morand EF. Evaluation of remission definitions for systemic lupus erythematosus: a prospective cohort study. Lancet Rheumatol 2019; 1:e103-e110. [PMID: 38229337 DOI: 10.1016/s2665-9913(19)30048-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Validated outcome measures are needed from which to derive treatment strategies for systemic lupus erythematosus (SLE). However, no definition of remission for SLE has been widely adopted. The Definitions of Remission in Systemic Lupus Erythematosus (DORIS) group has proposed a framework with multiple potential definitions of remission. In this study, we aimed to assess the attainability and effect on disease outcomes of the DORIS definitions of remission, compared with the lupus low disease activity state (LLDAS), in patients with SLE. METHODS In this prospective cohort study, we enrolled patients with SLE from 13 international centres that are part of the Asia Pacific Lupus Collaboration. Eligible patients were older than 18 years and fulfilled one of two classification criteria for SLE (1997 American College of Rheumatology criteria or the 2012 Systemic Lupus International Collaborating Clinics criteria). Visits were according to clinical need, with a minimum frequency of one visit per 6 months. We assessed attainment of remission on the basis of the eight DORIS definitions of remission, which varied in terms of serological activity, glucocorticoid use, and use of immunosuppresive agents; attainment of LLDAS; and disease flares at each visit. Irreversible organ damage accrual was recorded annually. Our primary aim was to assess exposure of patients to each of the remission definitions or LLDAS, and the respective association of these states with accrual of irreversible organ damage as the primary outcome measure. Occurrence of disease flares was the key secondary outcome. We used time-dependent Cox proportional hazards models and generalised linear models to assess DORIS definitions of remission and LLDAS in terms of their association with damage accrual and disease flares. FINDINGS Between May 1, 2013, and Dec 31, 2016, 1707 patients with SLE were recruited and followed for a mean of 2·2 years (SD 0·9), totalling 12 689 visits. Remission, depending on DORIS definition, was achieved in 581 (4·6%) to 4546 (35·8%) of 12 689 visits. Spending 50% or more of observed time in any remission state was associated with a significant reduction in damage accrual, except for the two most stringent remission definitions, for which the frequency of attainment was lowest. Remission definitions disallowing serological activity were associated with the greatest reductions in disease flares. LLDAS was more attainable than any remission definition and was associated with a similar magnitude of protection from damage accrual and disease flares. Sustained remission and LLDAS were associated with a wider spread of effect sizes for reduction in risk of damage. By analysing patients who met the definition for LLDAS but not remission, we found that LLDAS was significantly associated with reduction in damage accrual, independent of all definitions of remission, except the least stringent. INTERPRETATION Attainment of remission was associated with significant reductions in damage accrual and disease flares. LLDAS was more achievable than remission based on the DORIS criteria, but was similarly protective. Remission definitions with less stringency might be insufficiently distinct from LLDAS to substantially affect outcome measures, and further studies are needed to distinguish the protective effects of the various remission definitions. FUNDING UCB, GlaxoSmithKline, Janssen, Bristol-Myers Squibb, and AstraZeneca.
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Affiliation(s)
- Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
| | | | - Molla Huq
- Department of Rheumatology, The University of Melbourne, Melbourne, VIC, Australia
| | - Worawit Louthrenoo
- Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shue Fen Luo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Yeong-Jian Jan Wu
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | - Aisha Lateef
- Rheumatology Division, National University Hospital, Singapore
| | | | - 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
| | - Laniyati Hamijoyo
- Department of Internal Medicine, University of Padjadjaran, Bandung, Indonesia
| | - Yasuhiro Katsumata
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Madelynn Chan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Sean O'Neill
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Fiona Goldblatt
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Rheumatology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zhan Guo Li
- Department of Rheumatology and Immunology, People's Hospital Peking University Health Sciences Centre, Beijing, China
| | - Alberta Hoi
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Mandana Nikpour
- Department of Rheumatology, The University of Melbourne, Melbourne, VIC, Australia
| | - Eric F Morand
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
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Oon S, Huq M, Golder V, Ong PX, Morand EF, Nikpour M. Lupus Low Disease Activity State (LLDAS) discriminates responders in the BLISS-52 and BLISS-76 phase III trials of belimumab in systemic lupus erythematosus. Ann Rheum Dis 2019; 78:629-633. [PMID: 30679152 DOI: 10.1136/annrheumdis-2018-214427] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/17/2018] [Accepted: 01/03/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We evaluated the discriminant capacity of the Lupus Low Disease Activity State (LLDAS) in post-hoc analysis of data from the BLISS-52 and BLISS-76 trials of belimumab in systemic lupus erythematosus (SLE). METHODS LLDAS attainment, discrimination between belimumab and placebo arms, and the effects in subgroups with high disease activity at recruitment were evaluated at week 52 using appropriate descriptive statistics, χ2 test and logistic regression. RESULTS At week 52, for belimumab 10 mg/kg, 17.0% and 19.3% of patients who achieved a Systemic Lupus Erythematosus Responder Index-4 also attained LLDAS in BLISS-52 and BLISS-76, respectively. Significantly more patients attained LLDAS on belimumab 10 mg/kg compared with placebo (12.5% vs 5.8%, OR 2.32, p=0.02 for BLISS-52; 14.4% vs 7.8%, OR 1.98, p=0.04 for BLISS-76). In a subgroup analysis, the difference in week 52 LLDAS attainment between belimumab 10 mg/kg and placebo was greater in patients who had higher disease activity at baseline, compared with the overall group. CONCLUSIONS LLDAS was able to discriminate belimumab 10 mg/kg from placebo in the BLISS-52 and BLISS-76 trials. Our findings support the validity of LLDAS as an outcome measure in SLE clinical trials.
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Affiliation(s)
- Shereen Oon
- Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Molla Huq
- Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Vera Golder
- Monash University, Melbourne, Victoria, Australia
| | - Pei Xuan Ong
- Monash University, Melbourne, Victoria, Australia
| | | | - Mandana Nikpour
- Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
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Kandane‐Rathnayake R, Golder V, Louthrenoo W, Luo S, Jan Wu Y, Li Z, An Y, Lateef A, Sockalingam S, Navarra SV, Zamora L, Hamijoyo L, Katsumata Y, Harigai M, Chan M, O’Neill S, Goldblatt F, Hao Y, Zhang Z, Al‐Saleh J, Khamashta M, Takeuchi T, Tanaka Y, Bae S, Lau CS, Hoi A, Nikpour M, Morand EF. Development of the Asia Pacific Lupus Collaboration cohort. Int J Rheum Dis 2018; 22:425-433. [PMID: 30398013 DOI: 10.1111/1756-185x.13431] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 12/20/2022]
Affiliation(s)
| | - Vera Golder
- School of Clinical Sciences at Monash HealthMonash University Melbourne Victoria Australia
| | | | - Shue‐Fen Luo
- Chang Gung Memorial Hospital Taipei Taiwan
- Chang Gung Memorial Hospital Keelung Taiwan
| | - Yeong‐Jian Jan Wu
- Chang Gung Memorial Hospital Taipei Taiwan
- Chang Gung Memorial Hospital Keelung Taiwan
| | - Zhanguo Li
- People's Hospital, Peking University Health Science Center Beijing China
| | - Yuan An
- People's Hospital, Peking University Health Science Center Beijing China
| | - Aisha Lateef
- National University Hospital Singapore Singapore
| | | | | | - Leonid Zamora
- University of Santo Tomas Hospital Manila Philippines
| | | | | | | | | | - Sean O’Neill
- Rheumatology Liverpool Hospital, SWS Clinical SchoolUNSW and The Ingham Institute for Applied Medical Research Liverpool New South Wales Australia
| | - Fiona Goldblatt
- Royal Adelaide Hospital Adelaide New South Wales Australia
- Flinders Medical Centre Adelaide New South Wales Australia
| | - Yanjie Hao
- Peking University First Hospital Beijing China
| | | | | | | | | | - Yoshiya Tanaka
- University of Occupational and Environmental Health Kitakyushu Japan
| | - Sang‐Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases Seoul South Korea
| | | | - Alberta Hoi
- School of Clinical Sciences at Monash HealthMonash University Melbourne Victoria Australia
| | | | - Eric F. Morand
- School of Clinical Sciences at Monash HealthMonash University Melbourne Victoria Australia
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Golder V, Ooi JJY, Antony AS, Ko T, Morton S, Kandane-Rathnayake R, Morand EF, Hoi AY. Discordance of patient and physician health status concerns in systemic lupus erythematosus. Lupus 2017; 27:501-506. [PMID: 28764617 DOI: 10.1177/0961203317722412] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives To compare the health status concerns of patients with systemic lupus erythematosus (SLE) and of their physicians. Methods Cross-sectional questionnaire study of SLE patients and their treating physicians at a tertiary disease-specific outpatient clinic. Patients and physicians completed a questionnaire regarding their concern about specific disease manifestations and impact on quality of life. For each item, degree of concern was rated on a five-point Likert scale and summarized as median (interquartile range). Ratings between patients and physicians were compared using Mann-Whitney U tests. Results A total of 84 patients and 21 physicians participated. Patients' predominant concerns centred on function and fatigue, whereas physicians' concerns focused on SLE-related organ complications. Of the 10 highest ranked patient concerns, only two were common to the 10 highest ranked physician concerns, while physicians rated seven significantly differently; all 10 highest ranked physician concerns were rated significantly lower by patients. The three highest ranked patient concerns (fatigue, pain and feeling worn out) were routinely assessed by 47.6%, 42.9% and 9.5% of physicians, respectively. Conclusion There was significant discordance between SLE patient and physician health status concerns. Items which were ranked highly by patients were not assessed consistently by physicians, highlighting a significant gap in healthcare communication.
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Affiliation(s)
- V Golder
- 1 School of Clinical Sciences, Monash University, Australia.,2 Department of Rheumatology, Monash Health, Clayton, Australia
| | - J J Y Ooi
- 1 School of Clinical Sciences, Monash University, Australia.,3 Alfred Health, Melbourne, Australia
| | - A S Antony
- 2 Department of Rheumatology, Monash Health, Clayton, Australia
| | - T Ko
- 2 Department of Rheumatology, Monash Health, Clayton, Australia
| | - S Morton
- 2 Department of Rheumatology, Monash Health, Clayton, Australia
| | | | - E F Morand
- 1 School of Clinical Sciences, Monash University, Australia.,2 Department of Rheumatology, Monash Health, Clayton, Australia
| | - A Y Hoi
- 1 School of Clinical Sciences, Monash University, Australia.,2 Department of Rheumatology, Monash Health, Clayton, Australia
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Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease predominantly affecting women of childbearing age. New classification criteria for SLE have greater sensitivity and therefore improve the diagnostic certainty for some patients, especially those who may previously have been labelled as having undifferentiated symptoms. Uncontrolled disease activity leads to irreversible end-organ damage, which in turn increases the risk of premature death; early and sustained control of disease activity can usually be achieved by conventional immunosuppressant therapy. The development of biological therapy lags behind that for other rheumatic diseases, with belimumab being the only targeted therapy approved by the Therapeutic Goods Administration. "Treat-to-target" concepts are changing trial design and clinical practice, with evidence-based definition of response criteria in the form of remission and low disease activity now on the horizon. While new therapies are awaited, research should also focus on optimising the use of current therapy and improving the quality of care of patients with SLE.
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Golder V, Kandane-Rathnayake R, Hoi AYB, Huq M, Louthrenoo W, An Y, Li ZG, Luo SF, Sockalingam S, Lau CS, Mok MY, Lateef A, Franklyn K, Morton S, Navarra STV, Zamora L, Wu YJ, Hamijoyo L, Chan M, O'Neill S, Goldblatt F, Nikpour M, Morand EF. Association of the lupus low disease activity state (LLDAS) with health-related quality of life in a multinational prospective study. Arthritis Res Ther 2017; 19:62. [PMID: 28320433 PMCID: PMC5359963 DOI: 10.1186/s13075-017-1256-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/09/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is associated with significant impairment of health-related quality of life (HR-QoL). Recently, meeting a definition of a lupus low disease activity state (LLDAS), analogous to low disease activity in rheumatoid arthritis, was preliminarily validated as associated with protection from damage accrual. The LLDAS definition has not been previously evaluated for association with patient-reported outcomes. The objective of this study was to determine whether LLDAS is associated with better HR-QoL, and examine predictors of HR-QoL, in a large multiethnic, multinational cohort of patients with SLE. METHODS HR-QoL was measured using the Medical Outcomes Study 36-item short form health survey (SF-36v2) in a prospective study of 1422 patients. Disease status was measured using the SLE disease activity index (SLEDAI-2 K), physician global assessment (PGA) and LLDAS. RESULTS Significant differences in SF-36 domain scores were found between patients stratified by ethnic group, education level and damage score, and with the presence of active musculoskeletal or cutaneous manifestations. In multiple linear regression analysis, Asian ethnicity (p < 0.001), a higher level of education (p < 0.001), younger age (p < 0.001) and shorter disease duration (p < 0.01) remained significantly associated with better physical component scores (PCS). Musculoskeletal disease activity (p < 0.001) was negatively associated with PCS, and cutaneous activity (p = 0.04) was negatively associated with mental component scores (MCS). Patients in LLDAS had better PCS (p < 0.001) and MCS (p < 0.001) scores and significantly better scores in multiple individual SF-36 domain scores. Disease damage was associated with worse PCS (p < 0.001), but not MCS scores. CONCLUSIONS Ethnicity, education, disease damage and specific organ involvement impacts HR-QoL in SLE. Attainment of LLDAS is associated with better HR-QoL.
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Affiliation(s)
- Vera Golder
- Monash University School of Clinical Sciences at Monash Health, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Melbourne, Australia.
| | - Rangi Kandane-Rathnayake
- Monash University School of Clinical Sciences at Monash Health, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Melbourne, Australia
| | - Alberta Yik-Bun Hoi
- Monash University School of Clinical Sciences at Monash Health, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Melbourne, Australia
| | - Molla Huq
- The University of Melbourne, Melbourne, Australia
| | | | - Yuan An
- People's Hospital Peking University Health Sciences Center, Beijing, China
| | - Zhan Guo Li
- People's Hospital Peking University Health Sciences Center, Beijing, China
| | - Shue Fen Luo
- Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | | | | | - Mo Yin Mok
- University of Hong Kong, Pokfulam, Hong Kong
| | - Aisha Lateef
- National University Hospital, Singapore, Republic of Singapore
| | - Kate Franklyn
- Monash University School of Clinical Sciences at Monash Health, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Melbourne, Australia
| | | | | | - Leonid Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | - Yeong-Jian Wu
- Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | | | - Madelynn Chan
- Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Sean O'Neill
- University of New South Wales, Sydney, Australia
| | | | | | - Eric Francis Morand
- Monash University School of Clinical Sciences at Monash Health, Level 5, Block E, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Melbourne, Australia
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Golder V, Huq M, Franklyn K, Calderone A, Lateef A, Lau CS, Lee ALH, Navarra STV, Godfrey T, Oon S, Hoi AYB, Morand EF, Nikpour M. Does expert opinion match the operational definition of the Lupus Low Disease Activity State (LLDAS)? A case-based construct validity study. Semin Arthritis Rheum 2017; 46:798-803. [PMID: 28216192 DOI: 10.1016/j.semarthrit.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the construct validity of the Lupus Low Disease Activity State (LLDAS), a treatment target in systemic lupus erythematosus (SLE). METHODS Fifty SLE case summaries based on real patients were prepared and assessed independently for meeting the operational definition of LLDAS. Fifty international rheumatologists with expertise in SLE, but with no prior involvement in the LLDAS project, responded to a survey in which they were asked to categorize the disease activity state of each case as remission, low, moderate, or high. Agreement between expert opinion and LLDAS was assessed using Cohen's kappa. RESULTS Overall agreement between expert opinion and the operational definition of LLDAS was 77.96% (95% CI: 76.34-79.58%), with a Cohen's kappa of 0.57 (95% CI: 0.55-0.61). Of the cases (22 of 50) that fulfilled the operational definition of LLDAS, only 5.34% (59 of 22 × 50) of responses classified the cases as moderate/high activity. Of the cases that did not fulfill the operational definition of LLDAS (28 of 50), 35.14% (492 of 28 × 50) of responses classified the cases as remission/low activity. Common reasons for discordance were assignment to remission/low activity of cases with higher corticosteroid doses than defined in LLDAS (prednisolone ≤ 7.5mg) or with SLEDAI-2K >4 due to serological activity (high anti-dsDNA antibody and/or low complement). CONCLUSIONS LLDAS has good construct validity with high overall agreement between the operational definition of LLDAS and expert opinion. Discordance of results suggests that the operational definition of LLDAS is more stringent than expert opinion at defining a low disease activity state.
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Affiliation(s)
- Vera Golder
- School of Clinical Sciences, Monash University, Melbourne, Australia.
| | - Molla Huq
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Kate Franklyn
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alicia Calderone
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Aisha Lateef
- Rheumatology Division, National University Hospital, Singapore, Singapore
| | - Chak Sing Lau
- Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | | | | | - Timothy Godfrey
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - Shereen Oon
- Department of Medicine, Melbourne University, Melbourne, Australia
| | | | | | - Mandana Nikpour
- Department of Medicine, Melbourne University, Melbourne, Australia
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Golder V, Morand EF, Hoi AY. Quality of Care for Systemic Lupus Erythematosus: Mind the Knowledge Gap. J Rheumatol 2017; 44:271-278. [DOI: 10.3899/jrheum.160334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 02/03/2023]
Abstract
Systemic lupus erythematosus (SLE) is a prototypical chronic multiorgan autoimmune disorder that can lead to significant burden of disease and loss of life expectancy. The disease burden is the result of a complex interplay between genetic, biologic, socioeconomic, and health system variables affecting the individual. Recent advances in biological understanding of SLE are yet to translate to transformative therapies, and genetic and socioeconomic variables are not readily amenable to intervention. In contrast, healthcare quality, a variable readily amenable to change, has been inadequately addressed in SLE, despite evidence in other chronic diseases that quality of care is strongly associated with patient outcomes. This article will analyze the available literature on the quality of care relevant to SLE, identify knowledge gaps, and suggest ways to address this in future research.
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Golder V, Kandane-Rathnayake R, Hoi AYB, Huq M, Louthrenoo W, An Y, Li ZG, Luo SF, Sockalingam S, Lau CS, Lee AL, Mok MY, Lateef A, Franklyn K, Morton S, Navarra STV, Zamora L, Wu YJ, Hamijoyo L, Chan M, O'Neill S, Goldblatt F, Morand EF, Nikpour M. Frequency and predictors of the lupus low disease activity state in a multi-national and multi-ethnic cohort. Arthritis Res Ther 2016; 18:260. [PMID: 27829463 PMCID: PMC5103412 DOI: 10.1186/s13075-016-1163-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/24/2016] [Indexed: 12/28/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) is a chronic heterogeneous disease with considerable burden from disease activity and damage. A novel clinical treatment target in the form of the lupus low disease activity state (LLDAS) has been recently reported, with retrospective validation showing that time spent in LLDAS translates to reduced damage accrual. The objectives of this study were to describe the frequency and identify the predictors of attaining LLDAS in a large multinational cohort of patients with SLE. Methods Data were collected at the recruitment visit in patients with SLE enrolled in a longitudinal study in nine countries. Data were analysed cross-sectionally against the recently published definition of LLDAS, and the frequency and characteristics associated with presence of LLDAS were determined. Stepwise multivariable logistic regression was used to determine predictors of LLDAS. Results Of the 1846 patients assessed, criteria for LLDAS were met by 44 %. Patients with shorter disease duration were less likely to be in LLDAS (OR 0.31, 95 % CI 0.19–0.49, p < 0.001). Likewise, patients with a history of discoid rash (OR 0.66, 95 % CI 0.49–0.89, p = 0.006), renal disease (OR 0.60, 95 % CI 0.48–0.75, p < 0.001), elevated double stranded DNA (OR 0.65, 95 % CI 0.53–0.81, p < 0.001) or hypocomplementaemia (OR 0.52, 95 % CI 0.40–0.67, p < 0.001) were less likely to be in LLDAS. When countries were compared, higher national social wealth (OR 1.57, 95 % CI 1.25–1.98, p < 0.001) as measured by the gross domestic product per capita was positively associated with LLDAS, but ethnicity was not. Conclusion The lupus low disease activity state is observed in less than half of patients with SLE at a single point in time. Disease duration and phenotype, and national social wealth, are predictive of LLDAS. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1163-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Molla Huq
- The University of Melbourne, Melbourne, Australia
| | | | - Yuan An
- People's Hospital Peking University Health Sciences Center, Beijing, China
| | - Zhan Guo Li
- People's Hospital Peking University Health Sciences Center, Beijing, China
| | - Shue Fen Luo
- Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | | | | | | | - Mo Yin Mok
- University of Hong Kong, Hong Kong, Hong Kong
| | - Aisha Lateef
- National University Hospital, Singapore, Singapore
| | | | | | | | - Leonid Zamora
- University of Santo Tomas Hospital, Manila, Philippines
| | - Yeong-Jian Wu
- Chang Gung Memorial Hospital, Guishan Township, Taiwan
| | | | | | - Sean O'Neill
- University of New South Wales, Sydney, Australia
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Golder V, Kandane-Rathnayake R, Hoi A, Louthrenoo W, An Y, Li Z, Luo S, Sockalingam S, Lau C, Lee A, Mok M, Lateef A, Franklyn K, Navarra S, Zamora L, Wu YJ, Hamijoyo L, Chan M, O'Neill S, Goldblatt F, Huq M, Nikpour M, Morand E. SAT0282 Frequency and Predictors of Attainment of The Lupus Low Disease Activity State (LLDAS) in A Cross Sectional Study of Sle Patients in The Asia Pacific. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.1752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Two cases of disseminated enteroviral infection occurred in patients who received the CD20 monoclonal antibody obinutuzumab. Clinical features included hepatitis, edema, and a dermatomyositis-like syndrome. These manifestations may be unfamiliar to clinicians and are possibly responsive to intravenous immunoglobulin. Clinicians should remain vigilant for enteroviral infections in patients receiving obinutuzumab.
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Golder V, Schachna L. Ankylosing spondylitis: an update. Aust Fam Physician 2013; 42:780-784. [PMID: 24217097] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Ankylosing spondylitis (AS) affects one in 200 individuals and is usually diagnosed many years after onset of symptoms. Chronic back pain is common and recognition of early disease requires clinical experience and a high index of suspicion. Further, inflammatory markers are not invariably elevated and radiographic changes are often late findings. OBJECTIVE The objective of this review is to address AS and the recently defined disorder of non-radiographic axial spondyloarthritis. The latter is a common early presentation of AS, before the development of radiographic sacroiliitis, and will evolve into typical AS in 50% of patients. DISCUSSION MRI may be particularly useful in evaluating early disease, although chronic changes of sacroiliitis are better seen on plain X-rays. Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line therapy and recent studies suggest that regular use among patients with AS slows radiographic progression. Tumour necrosis inhibitor therapy has strikingly improved quality of life for the more than two-thirds of AS patients with an inadequate response to NSAIDs.
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Affiliation(s)
- Vera Golder
- MBBS, Advanced Trainee in Rheumatology, Austin Health, Melbourne, Victoria
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Golder V, Connelly K, Staples M, Morand E, Hoi A. Association of Asian ethnicity with disease activity in SLE: an observational study from the Monash Lupus Clinic. Lupus 2013; 22:1425-30. [PMID: 23942610 DOI: 10.1177/0961203313500547] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE), an autoimmune condition with diverse clinical manifestations, is reported to have different expression in populations of different ancestry. Most previous studies compared patients of different ethnic groups from geographically distinct cohorts. In our study, we aimed to characterize disease manifestations in patients of different ethnic groups from a single centre, and studied patterns of disease activity over time. METHODS Demographics, baseline disease characteristics and autoantibody profiles, and disease activity (SLEDAI) measured at each visit, were captured from all consenting patients prospectively followed between 2007 and 2011 in an urban teaching hospital lupus clinic. Ethnicity was self-reported. RESULTS Asian ethnicity was significantly associated with more clinically severe SLE. Time-adjusted mean SLEDAI (p = 0.01) and maximum SLEDAI (p = 0.0018) were significantly higher in Asian patients. Asians were more likely to have renal disease (OR 2.9, 95% CI 1.4-5.98; p = 0.004) and persistently active disease (PAD) (OR 2.14, 95% CI 1.05-4.38, p = 0.04). Asian lupus patients also had a significantly higher proportion of autoantibody positivity to anti-dsDNA, anti-RNP, anti-Sm, anti-Ro and anti-La, as well as increased likelihood of hypocomplementaemia and immunosuppressant use. CONCLUSION In this single-cohort study, Asian ethnicity was found to be associated with increased SLE disease activity. This suggests significant inter-ethnic genetic contributions to the regulation of autoimmune responses and disease severity in SLE.
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Affiliation(s)
- V Golder
- Monash University, Monash Medical Centre, Australia
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Golder V, Hepponstall M, Yiallourou SR, Odoi A, Horne RSC. Autonomic cardiovascular control in hypotensive critically ill preterm infants is impaired during the first days of life. Early Hum Dev 2013; 89:419-23. [PMID: 23313567 DOI: 10.1016/j.earlhumdev.2012.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/15/2012] [Accepted: 12/20/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND The first days after preterm birth are a critical period of cardiovascular instability, where hypotension is common. We assessed autonomic cardiovascular function by measuring heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity (BRS) and hypothesised that these would be impaired in preterm infants born at younger gestational ages. In addition, we speculated that impaired cardiovascular control could be used as a marker of circulatory failure such as is manifest as hypotension. METHODS 23 preterm infants (11 M/12 F) born between 23 and 35 weeks (mean 27 ± 0.6 weeks) gestational age with indwelling arterial catheters were recruited. Infants were studied over the first 3 days of life with heart rate and blood pressure (BP) analysed beat to beat in the frequency domain in 2 minute epochs of artefact free data during active sleep. Data were compared with one way ANOVA. RESULTS Gestational age was correlated with all HRV indices but not BPV or BRS. 9 babies received inotropes. Gestational age between the inotrope group and the non-inotrope group was not different. BP and RR interval were lower in the inotrope group (40.7 ± 1.5 vs 47.1 ± 1.5 mmHg, p<0.05 and 395 ± 14 vs 426 ± 11 ms, p<0.08). BRS was also lower in the inotrope group (3.8 ± 0.9 vs 6.9 ± 1.6 ms/mmHg) as was LF/HF HRV (5.7 ± 1.3 vs 13.6 ± 2.8, p<0.05). CONCLUSIONS In the first 3 days after birth, infants receiving inotropes had significantly impaired cardiovascular control compared to those who did not receive treatment, indicating that these infants maybe predisposed to increased vulnerability to circulatory instability.
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Affiliation(s)
- Vera Golder
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Victoria 3168, Australia
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