Long-term follow-up of the MAINTAIN Nephritis Trial, comparing azathioprine and mycophenolate mofetil as maintenance therapy of lupus nephritis

Objective

To report the 10-year follow-up of the MAINTAIN Nephritis Trial comparing azathioprine (AZA) and mycophenolate mofetil (MMF) as maintenance therapy of proliferative lupus nephritis, and to test different definitions of early response as predictors of long-term renal outcome.

Methods

In 2014, data on survival, kidney function, 24 h proteinuria, renal flares and other outcomes were collected for the 105 patients randomised between 2002 and 2006, except in 13 lost to follow-up.

Results

Death (2 and 3 in the AZA and MMF groups, respectively) and end-stage renal disease (1 and 3, respectively) were rare events. Time to renal flare (22 and 19 flares in AZA and MMF groups, respectively) did not differ between AZA and MMF patients. Patients with good long-term renal outcome had a much more stringent early decrease of 24 h proteinuria compared with patients with poor outcome. The positive predictive value of a 24 h proteinuria <0.5 g/day at 3 months, 6 months and 12 months for a good long-term renal outcome was excellent (between 89% and 92%). Inclusion of renal function and urinalysis in the early response criteria did not impact the value of early proteinuria decrease as long-term prognostic marker.

Conclusions

The long-term follow-up data of the MAINTAIN Nephritis Trial do not indicate that MMF is superior to AZA as maintenance therapy in a Caucasian population suffering from proliferative lupus nephritis. Moreover, we confirm the excellent positive predictive value of an early proteinuria decrease for long-term renal outcome.

Trial registration number

NCT00204022.

Azathioprine versus mycophenolate mofetil for long-term immunosuppression in lupus nephritis: results from the MAINTAIN Nephritis Trial

Background

Long-term immunosuppressive treatment does not efficiently prevent relapses of lupus nephritis (LN). This investigator-initiated randomised trial tested whether mycophenolate mofetil (MMF) was superior to azathioprine (AZA) as maintenance treatment.

Methods

A total of 105 patients with lupus with proliferative LN were included. All received three daily intravenous pulses of 750 mg methylprednisolone, followed by oral glucocorticoids and six fortnightly cyclophosphamide intravenous pulses of 500 mg. Based on randomisation performed at baseline, AZA (target dose: 2 mg/kg/day) or MMF (target dose: 2 g/day) was given at week 12. Analyses were by intent to treat. Time to renal flare was the primary end point. Mean (SD) follow-up of the intent-to-treat population was 48 (14) months.

Results

The baseline clinical, biological and pathological characteristics of patients allocated to AZA or MMF did not differ. Renal flares were observed in 13 (25%) AZA-treated and 10 (19%) MMF-treated patients. Time to renal flare, to severe systemic flare, to benign flare and to renal remission did not statistically differ. Over a 3-year period, 24 h proteinuria, serum creatinine, serum albumin, serum C3, haemoglobin and global disease activity scores improved similarly in both groups. Doubling of serum creatinine occurred in four AZA-treated and three MMF-treated patients. Adverse events did not differ between the groups except for haematological cytopenias, which were statistically more frequent in the AZA group (p=0.03) but led only one patient to drop out.

Conclusions

Fewer renal flares were observed in patients receiving MMF but the difference did not reach statistical significance.

EULAR points to consider for conducting clinical trials in systemic lupus erythematosus: literature based evidence for the selection of endpoints: Table 1

Objective:

To assess available evidence on the use of end-points (outcome measures) in clinical trials in systemic lupus erythematosus (SLE), as a part of the development of evidence-based recommendations for points to consider in clinical trials in SLE.

Methods:

The European League Against Rheumatism (EULAR) Task Force on SLE comprised 19 specialists, a clinical epidemiologist and a research fellow. Key questions addressing the evidence for clinical trial end-points in SLE were compiled using the Delphi technique. A systematic search of the PubMed and Cochrane Library databases was performed using McMaster/Hedges clinical query strategies and an array of relevant terms. Evidence was categorised based on sample size and type of design, and the categories of available evidence were identified for each recommendation. The strength of recommendation was assessed based on the category of available evidence and agreement on the statements was measured across the 19 specialists.

Results:

Eight questions were generated regarding end-points for clinical trials. The evidence to support each proposition was evaluated. The literature review revealed that most outcome measures used in phase 2/3 trials in SLE have not been formally validated in clinical trials, although some indirect validation has been undertaken.

Conclusion:

This systematic literature review forms the evidence base considered in the development of the EULAR recommendations for end-points in clinical trials in SLE.

EULAR recommendations for the management of systemic lupus erythematosus. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics

OBJECTIVE

Systemic lupus erythematosus (SLE) is a complex disease with variable presentations, course and prognosis. We sought to develop evidence-based recommendations addressing the major issues in the management of SLE.

METHODS

The EULAR Task Force on SLE comprised 19 specialists and a clinical epidemiologist. Key questions for the management of SLE were compiled using the Delphi technique. A systematic search of PubMed and Cochrane Library Reports was performed using McMaster/Hedges clinical queries' strategies for questions related to the diagnosis, prognosis, monitoring and treatment of SLE. For neuropsychiatric, pregnancy and antiphospholipid syndrome questions, the search was conducted using an array of relevant terms. Evidence was categorised based on sample size and type of design, and the categories of available evidence were identified for each recommendation. The strength of recommendation was assessed based on the category of available evidence, and agreement on the statements was measured across the 19 specialists.

RESULTS

Twelve questions were generated regarding the prognosis, diagnosis, monitoring and treatment of SLE, including neuropsychiatric SLE, pregnancy, the antiphospholipid syndrome and lupus nephritis. The evidence to support each proposition was evaluated and scored. After discussion and votes, the final recommendations were presented using brief statements. The average agreement among experts was 8.8 out of 10.

CONCLUSION

Recommendations for the management of SLE were developed using an evidence-based approach followed by expert consensus with high level of agreement among the experts.

Association analysis of the 1858C>T polymorphism in the PTPN22 gene in juvenile idiopathic arthritis and other autoimmune diseases

A functional single nucleotide polymorphism, 1858C>T, in the PTPN22 gene, encoding a tyrosine phosphatase, has been reported to be associated with type I diabetes and some other autoimmune diseases. To further investigate whether this polymorphism may be a general susceptibility factor for autoimmunity, we performed an association study in five different autoimmune diseases, three previously not tested. We found an association with juvenile idiopathic arthritis (OR=1.41; P=0.04), not previously reported, and a tendency for an association with coeliac disease (OR=1.35; P=0.08). In primary sclerosing cholangitis, no association was observed (OR=0.95; P=0.8). Furthermore, we confirmed the increased risk in rheumatoid arthritis (OR=1.58; P=0.001), but could not find support for an association with systemic lupus erythematosus (OR=0.94; P=0.8). Altogether, we have provided further evidence of an association between autoimmune diseases and the 1858C>T polymorphism in PTPN22.

Sicca symptoms and secondary Sjögren's syndrome in systemic lupus erythematosus: comparison with rheumatoid arthritis and correlation with disease variables

OBJECTIVE

Firstly, to study the prevalence of ocular and oral sicca symptoms, reduced tear and saliva production, and the minimum frequency of secondary Sjögren's syndrome (sSS) in systemic lupus erythematosus (SLE). Secondly, to compare sicca symptoms and findings with those of matched patients with rheumatoid arthritis (RA), and sicca symptoms with those in healthy controls. Finally, to study possible associations of clinical variables with sicca symptoms and sSS in SLE.

METHODS

Self reported sicca symptoms were recorded in 81 patients with SLE aged < or =70, 81 matched patients with RA, and 81 matched healthy controls. Other study variables included Schirmer-I test (S1T), unstimulated whole saliva, health status measures (in SLE and RA), disease activity, accumulated organ damage, and serological markers (in SLE).

RESULTS

A significantly higher proportion of patients with SLE reported sicca symptoms than healthy controls. Further, a significantly higher proportion reported ocular sicca symptoms (43 and 21%, respectively) and had pathologically reduced S1T compared with RA (46 and 21%, respectively). No difference was seen in oral sicca symptoms and saliva production. In SLE, sicca symptoms were associated with fatigue, and sSS with anti-SSB or anti-SSA antibodies, or both.

CONCLUSIONS

An increased prevalence of sicca symptoms was found in patients with SLE compared with controls, and a higher prevalence of ocular sicca symptoms and reduced tear production in SLE compared with RA. Sicca problems should be considered in the care of patients with SLE, especially those with anti-SSB and/or anti-SSA antibodies who have sicca symptoms and fatigue.

Disease course in systemic lupus erythematosus: changes in health status, disease activity, and organ damage after 2 years

OBJECTIVE

To examine changes in health status, disease activity, and organ damage after 2 years and to study possible disease variables predicting change in health status, disease activity, and organ damage at followup in systemic lupus erythematosus (SLE). Second, to compare changes in health status in patients with SLE to that of matched patients with rheumatoid arthritis (RA) and matched healthy controls.

METHODS

A 2 year longitudinal observational study, measuring health status (Short-Form 36. visual analog scale for pain and fatigue, modified Health Assessment Questionnaire, patient global assessment of disease activity), disease activity, and organ damage in 87 patients with SLE. Health status measures in SLE were compared to 65 matched RA patients selected from the Oslo RA register and to 77 matched healthy controls from the population register.

RESULTS

On a group level the SLE patients showed stable health status measures and disease activity scores 2 years after baseline, but organ damage scores increased significantly. Increase in organ damage was significantly and independently predicted by baseline scores of disease activity and organ damage, health status, and disease activity by the respective baseline scores. Changes in health status measures over 2 years were similar in SLE, RA, and healthy controls.

CONCLUSION

Our 2 year longitudinal observational SLE study showed a stable course of health status and disease activity, whereas organ damage increased. Disease activity and organ damage at baseline predicted the latter. Our results indicate the value of careful monitoring of disease activity over time in SLE and individually tailored treatment guided by the predictors of course and outcome.

Bone mineral density in systemic lupus erythematosus: comparison with rheumatoid arthritis and healthy controls

OBJECTIVES

To examine bone mineral density (BMD) frequency of osteoporosis and reduced bone mass in systemic lupus erythematosus (SLE), and compare the data of the SLE patients with matched rheumatoid arthritis (RA) patients and healthy controls. Secondly, to study possible correlations between BMD, demographic and disease variables in the SLE patients.

METHODS

Measures of BMD assessed by dual energy x ray absorptiometry were obtained from 75 SLE patients aged </= 70 years, 75 RA patients matched for age, sex and disease duration, and from 75 healthy controls matched for age, sex and geographical area. Disease activity and accumulated organ damage were assessed in the SLE patients.

RESULTS

The SLE patients had significantly lower BMD values at lumbar spine L2-L4 and hip, and higher frequency of osteoporosis at all sites of measurement compared with matched healthy controls. The matched SLE and RA patients had similar BMD, prevalence of osteoporosis and reduced bone mass. In the SLE patients BMD was more strongly correlated with accumulated organ damage than with markers of disease activity or duration. In multivariate analyses BMD was at all sites predicted by age and body mass, at lumbar spine also by the current corticosteroid dose.

CONCLUSION

The study showed reduced BMD in patients with SLE compared with matched healthy controls. Premenopausal women taking corticosteroids were especially affected. Furthermore, the BMD of matched SLE and RA patients was reduced to a similar extent.

Oral and ocular sicca symptoms and findings are prevalent in systemic lupus erythematosus

The aims of this study were 1) to examine the frequency of oral and ocular sicca symptoms in patients with systemic lupus erythematosus (SLE); 2) to compare saliva and tear volume, salivary proteins, and features of the oral microflora and mucosa to a matched healthy control group; and 3) to relate the findings to disease parameters. Median disease duration was 5.5 (0.5-28) years, disease activity 5 (2-20), damage score 1 (0-7), and Schirmer I test 7.5 (0-30 mm). Seventeen and twelve patients complained of oral and ocular dryness, respectively. Unstimulated whole saliva and proline-rich proteins in submandibular saliva were significantly reduced in SLE. Oral microbial counts were generally higher in the patients than controls, and the number of oral mucosal changes was increased. The results show that sicca symptoms, although frequent, were not correlated to secretory rates of saliva or tears, but to oral microbial counts. There was no obvious correlation to patient's age, disease activity or duration.

Health status in systemic lupus erythematosus compared to rheumatoid arthritis and healthy controls

OBJECTIVE

To examine health status in systemic lupus erythematosus (SLE), using both generic and arthritis-specific instruments, and compare the health status in patients with SLE to matched patients with rheumatoid arthritis (RA) and matched healthy controls. As well, to study possible correlations between health status measures and demographic and disease variables in the patients with SLE.

METHODS

Patients were recruited from the Oslo county registers of patients with SLE and RA, and the healthy controls from the county population register. Measures of health status (Medical Outcome Survey SF-36, joint pain and fatigue on visual analog scale, Modified Health Assessment Questionnaire) were obtained from 82 SLE and 82 RA patients matched for age, sex, and disease duration, and from 74 age and sex matched healthy controls. Disease activity and organ damage were assessed in the patients with SLE.

RESULTS

Patients with SLE were significantly more affected in all dimensions of health status compared to controls, except in the SF-36 category role-emotional. Further, patients with SLE were significantly less affected than patients with RA with regard to physical function and joint pain, but scores were similar in all other dimensions of health status. Scores of health status correlated more strongly to the damage index than to disease activity, indicating that health status measures capture some of the same concept as the damage index, namely the consequence of the disease over time.

CONCLUSION

Our study showed that patients with SLE and RA have a multidimensional involvement of health status compared to healthy controls. The findings call for a biopsychosocial approach in the management of SLE.

Application of the 1982 revised criteria for the classification of systemic lupus erythematosus on a cohort of 346 Norwegian patients with connective tissue disease

By reviewing patient's records, we evaluated the sensitivity and specificity of the 1982 revised classification criteria for systemic lupus erythematosus on a cohort of 346 Norwegian patients with connective tissue disease, seen at a rheumatology referral center in the period 1986-95. The patients with CTD other than SLE were used as controls. The number of the 1982 revised classification criteria for SLE fulfilled by each individual patient was calculated. Fifty-five of the 76 SLE patients (72%) met four or more criteria for SLE, giving a low sensitivity of 72%. Twenty-three of the 270 patients with CTD other than SLE (9%) met four or more criteria for SLE, giving an acceptable specificity of 91%. Applying the "revised/revised 1997 ACR criteria for SLE" the sensitivity would have increased to 78% and the specificity reduced to 89%. The sample of SLE patients was characterized by mild disease with a low proportion of severe internal manifestations.

Conversion of patients with rheumatoid arthritis from the conventional to a microemulsion formulation of cyclosporine: a double blind comparison to screen for differences in safety, efficacy, and pharmacokinetics

OBJECTIVE

To assess whether patients with rheumatoid arthritis (RA) may be converted, on a milligram-to-milligram basis, from conventional cyclosporin A (CyA, Sandimmun) to the microemulsion formulation (Neoral) with maintenance of longterm safety, and to compare cyclosporin A (CyA) pharmacokinetics between formulations.

METHODS

In this double blind, multicenter, parallel group study, 51 patients receiving stable conventional CyA maintenance treatment were randomized to continue conventional CyA (n = 27) or to convert to CyA microemulsion (n = 24) and were monitored for 52 weeks. Trough blood CyA levels were measured before and at intervals after conversion. CyA steady-state area under the curve was assessed one week before and 2 and 6 weeks after randomization in 15 patients in each treatment arm. CyA trough levels and pharmacokinetic results remained unknown to investigators throughout the study. CyA doses were titrated as necessary on the basis of clinical evaluation and disease activity assessments.

RESULTS

Initial mean daily doses were 3.5 mg/kg/day (conventional CyA) and 3.3 mg/kg/day (CyA microemulsion) and did not change significantly during the study. The mean bioavailability of CyA from the microemulsion formulation was 23% higher than from conventional CyA. Replicate assessments indicated a more reproducible pharmacokinetic profile with CyA microemulsion. The overall incidence and nature of adverse events and changes in vital signs and laboratory variables were similar in both groups. No clinically relevant differences in efficacy were found between treatments. No loss of efficacy and no tolerability problems occurred after conversion from conventional to microemulsion CyA.

CONCLUSION

Existing CyA dosing guidelines, formulated for conventional CyA, are suitable for longterm CyA microemulsion therapy of patients with RA. These results indicate the pharmacokinetic advantages of the microemulsion formulation.

Nutrient intake and nutritional status in children with juvenile chronic arthritis

Nutrient intake and nutritional status were assessed in 15 children with juvenile chronic arthritis (JCA) and in 17 healthy controls. Anthropometric measurements were similar in children with pauciarticular JCA and in controls, whereas weight (p = 0.05) and upper arm muscle area (UAMA) (p less than 0.01) were reduced in children with polyarticular JCA. Compared with healthy controls the concentrations of hemoglobin, serum iron and serum zinc were reduced in the children with polyarticular JCA (p less than 0.01) and serum copper was increased (p less than 0.01). In the patients the concentrations of hemoglobin, serum iron and serum zinc correlated negatively with erythrocyte sedimentation rate (ESR), whereas serum copper correlated positively. Impaired nutritional status was found in the children with polyarticular JCA in spite of increased energy and protein intake. In this group of patients the dietary intake of calcium was also found to be reduced.