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Dedicated to increasing awareness about
systemic lupus erythematosus (SLE), disease activity and related organ damage

Treatment Considerations for Optimizing Patient Care

In the treatment of SLE, there is a lack of consensus on what remission means. While the term remission has been used to describe a favorable clinical state for SLE, an agreed-upon definition of remission in SLE has yet to be made.1

As a result, when remission is not possible, consider alternative targets. Treat-to-Target is a therapeutic strategy with the view to improve disease outcomes.2

The treatment target of SLE should be remission of systemic symptoms, organ manifestations or, where remission cannot be reached, the lowest possible disease activity, measured by a validated lupus activity index and/or organ-specific monitors.3

Low-disease activity would be a subsequent goal if clinical remission is not achievable3
Clinical remission (complete or partial) can be an effective target as well3
Complete remission is the goal for patients with SLE4

A selection of recommendations from various peer-reviewed sources and task forces include the following:

Minimize disease activity

  • Persistent disease activity can result in ongoing organ damage5
    • Since damage predicts subsequent damage and death, prevention of the damage accrual should be a major therapeutic goal in SLE3
  • Disease activity and immunologic factors can predict flares
    • Prevention of flares (especially severe flares) is a realistic target in SLE and should be a therapeutic goal3
    • Assess disease activity regularly; patient history, physical assessment, and labs can help detect and define disease activity6-9
  • Factors negatively influencing quality of life such as fatigue, pain, and depression should be addressed in addition to control of disease activity and prevention of damage3

Monitor for subclinical activity

  • Regular monitoring should be undertaken to detect "silent variables"10
  • Data support following patients with mild or inactive disease at 3-4 month intervals10

Reduce as Much as Possible Glucocorticoid Dosage

  • Glucocorticoids are invaluable in the treatment of SLE; however, their chronic use has consistently shown to increase irreversible damage in lupus patients, a major predictor of morbidity and mortality11
Glucocorticoids
≥7.5 mg/day
right arrow 1.7X greater risk of
developing
any new
organ damage*,11

* Based on an analysis of data from the Hopkins Lupus Cohort study of 2,265 patients over 26 years, investigating impact of [glucocorticoid] doses on risk of organ damage development. At the time of this analysis, the cohort included 2,265 patients with SLE who were followed over the course of 26 years between 1987 and October 2012, with the average duration of follow-up from cohort entry until lost to follow-up being 6.2 years. Cox proportional hazards models were used to estimate the impact of different levels of exposure to [glucocorticoids] (as defined by [glucocorticoid] cut-off points endorsed in some SLE clinical trials) on the risk of developing any new organ damage or any new organ damage at the individual organ systems over time. Organ damage was measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) or by components of the SDI at the individual organ systems level.

  • In general, the risk of organ damage increases at 7.5 mg/day11
    • Use of the lowest effective dose of glucocorticoids can reduce the risk of glucocorticoid-related damage accrual3,12
  • SLE maintenance treatment should aim for the lowest glucocorticoid dosage needed to control disease — if possible, glucocorticoids should be withdrawn completely3

Treat-to-Target can be successful if the appropriate target(s) can be identified, measuring the target is possible, and appropriate interventions exist to (attempt to) achieve the target.3

PATIENT CASE STUDY: ALICIA

patient alicia

Alicia has been treated with glucocorticoids but still experiences frequent mobility and fatigue issues, as well as arthritis flares.

This is a hypothetical patient.

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LEARN MORE ABOUT SLE

This slide deck discusses the path to diagnosis of SLE, pathogenesis of the disease, impact on patients, and how to best support patients.

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What Next?

Patient care is a team effort that is critical in the management of SLE.13

Learn more now

References:
1. van Vollenhoven RF, et al. Remission in SLE: closing in on the target. Ann Rheum Dis. 2015;74(12):2103-6. http://dx.doi.org/10.1136/annrheumdis-2015-208231. Accessed February 14, 2017. 2. Doria A, Gatto M, Iaccarino L, et al. Value and goals of treat-to-target in systemic lupus erythematosus: knowledge and foresight. Lupus. 2015;24 (4-5):507-15. http://dx.doi.org/10.1177/0961203314559087. Accessed February 14, 2017. 3. van Vollenhoven RF, Mosca M, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis. 2014;73(6):958-967. http://dx.doi.org/10.1136/annrheumdis-2013-205139. Accessed February 14, 2017. 4. Zen M, Iaccarino L, Gatto M, et al. Prolonged remission in Caucasian patients with SLE: prevalence and outcomes. Ann Rheum Dis. 2015;74:2117-2122. http://dx.doi.org/10.1136/annrheumdis-2015-207347. Accessed February 14, 2017. 5. Lopez R, Davidson JE, Beeby MD, et al. Lupus disease activity and the risk of subsequent organ damage and mortality in a large lupus cohort. Rheumatology. 2012;51:491-498. http://dx.doi.org/10.1093/rheumatology/ker368. Accessed February 14, 2017. 6. Guidelines for referral and management of systemic lupus erythematosus in adults. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines. Arthritis Rheum. 1999;42(9):1785-1796. http://www.ncbi.nlm.nih.gov/pubmed/10513791. Accessed February 14, 2017. 7. Hahn BH, McMahon MA, Wilkinson A, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res. (Hoboken). 2012;64(6):797-808. http://dx.doi.org/10.1002/acr.21664. Accessed February 14, 2017. 8. Mosca M, Tani C, Aringer M, et al. European League Against Rheumatism recommendations for monitoring patients with systemic lupus erythematosus in clinical practice and in observational studies. Ann Rheum Dis. 2010;69(7):1269-1274. http://dx.doi.org/10.1136%2Fard.2009.117200. Accessed February 14, 2017. 9. Lam GK, Petri M. Assessment of systemic lupus erythematosus. Clin Exp Rheumatol. 2005;23 (5 suppl 39):S120-S132. http://www.clinexprheumatol.org/article.asp?a=2697. Accessed February 14, 2017. 10. Gladman DD, Ibañez D, Ruiz I, et al. Recommendations for frequency of visits to monitor systemic lupus erythematosus in asymptomatic patients: data from an observational cohort study. J Rheumatol. 2013;40(5):630-3. http://dx.doi.org/10.3899/jrheum.121094. Accessed February 14, 2017. 11. Ruiz-Irastorra G, Danza A, Khamashta M. Glucocorticoid use and abuse in SLE. Rheumatology. 2012;51:1145-1153. http://dx.doi.org/10.1093/rheumatology/ker410. Accessed February 14, 2017. 12. Thamer M, Hernan MA, Zhang Y, et al. Relationship between prednisone, lupus activity, and permanent organ damage. J Rheumatol. 2009:36(3):560-64. http://dx.doi.org/10.3899/jrheum.080828. Accessed February 14, 2017. 13. Askanase A. Systemic Lupus Erythematosus (SLE): Understanding and Addressing Patient Needs. Patient Care Insights. http://www.talksle.com/assets/patient_care_insights
_newsletter.pdf. Accessed February 14, 2017.