Fulfilling definitions for prolonged lupus remission and reaching a low disease activity state are both associated with a lower risk of damage accrual in lupus patients, new research confirms.
“Identifying predictors of organ damage holds great importance for improving outcomes in SLE [systemic lupus erythematosus]” in light of the strength of organ damage in predicting mortality in people with SLE, wrote the investigators of the new study, led by Michael W. P. Tsang-A-Sjoe of the Amsterdam Rheumatology and Immunology Center, VU University Medical Center, the Netherlands.
The investigators prospectively assessed 183 patients from the Amsterdam SLE cohort for flares and once a year for retrospectively determined remission as defined in a 2015 study ( Ann Rheum Dis. 2015;74:2117-22 ) and in Lupus Low Disease Activity State (LLDAS) criteria set by the Asia-Pacific Lupus Collaboration ( Ann Rheum Dis. 2016;75:1615-21 ). The research team developed a prediction model for damage accrual during the 5-year follow-up through the use of backward logistic regression analyses that took these definitions into account ( Rheumatology [Oxford]. 2016 Nov 1. doi: 10.1093/rheumatology/kew377 ).
The occurrence of at least one flare and the average daily prednisone dose during follow-up were significant predictors of damage accrual (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index increase of 5 or more during follow-up) in the cohort of patients with or without prolonged remission and with or without LLDAS in half or more of the observations. For example, patients had a higher risk of damage accrual with both a mean daily oral prednisone dose greater than 7.5 mg (odds ratio, 3.6; 95% confidence interval, 1.8-7.2) and greater than 5 mg (OR, 2.8; 95% CI, 1.5-5.3), compared with those taking lower doses.
The researchers also identified a history of nephrological manifestations at baseline as a significant predictor of damage accrual, despite not being part of the criteria for remission or LLDAS.
Overall, 38 (32.5%) of 117 patients met the prolonged remission criteria, whereas LLDAS in half or more of the available observations occurred in 118 (64.5%) of 183 patients.
Prolonged remission during 5 years of follow-up and LLDAS in 50% or more of observations were associated with a reduced risk of damage accrual (OR, 0.20; 95% CI, 0.07-0.53; P = .001; and OR, 0.52; 95% CI, 0.28-0.99, P = .046, respectively).
The effects of both remission and LLDAS, according to the definitions used in the study, don’t settle the matter of which might be used in a treat-to-target strategy. Neither the remission criteria nor the LLDAS definition showed clear superiority over the other, although patients in prolonged remission seemed to accrue less damage, compared with patients classified as being in LLDAS. However, the study did not prove this point, and the investigators noted that “future studies with sufficient power are needed in order to directly compare both sets of criteria for superiority.”
The results might also point to the possibility of lengthening the interval between disease activity assessments. The current study assessed LLDAS and remission at 1 year, compared with other studies that have generally assessed patients at quarterly intervals.
“This finding is interesting because it suggests that in clinical practice, yearly – rather than quarterly – assessments of LLDAS and remission might be sufficient to identify patients at risk of damage accrual, although future studies are needed to confirm this finding,” they wrote.
The study had no specific funding source, and the authors declared having no conflicts of interest.