The first study examining the independent impact of remission and LDA definitions on damage accrual.
INTRODUCTION
Systemic lupus erythematosus (often called Lupus or SLE) is an autoimmune disease. It typically starts in women between the ages of 15 and 45. Lupus symptoms can vary from patient to patient. People with Lupus are often very tired, have joint pain, and their skin may be sensitive to sunlight. Lupus often also affects a person’s inner organs, such as their kidneys, lungs, or brain. Lupus is caused by hyperactive immune cells and the production of autoantibodies. An antibody is a protein that the immune system makes to attack foreign substances in the body, such as viruses or bacteria. In autoimmune diseases, the body makes antibodies that attack its own tissues. These are called autoantibodies. The aim of treatment is to reduce symptoms, and prevent long-term damage. Healthcare professionals often use a series of targets to work out if you are responding to treatment. Different definitions for remission and low disease activity (shortened to LDA) have been proposed. Remission is when there are no signs and symptoms of active disease. This can be measured using a number of different tools, and might be defined as remission on- or off-treatment. The independent impact of these different definitions has not been evaluated. In addition,what level of. So far, at least differents have been Achieving remission or LDA is important, since these states have been associated with better overall health-re- lated quality of life, and therefore also with a lower probability of flares, hospitalisation, damage, cardiovas- cular events, costs, and death.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to evaluate a set of proposed definitions in a multinational, multi-ethnic group of people.
WHO WAS STUDIED?
The study looked at data from 1,652 people taking part in the SLICC cohort – a multinational study at 33 centres in Asia, Europe, and North America. The study took place from 1999 to 2011. Everyone included in the study had made at least two clinic visits.
HOW WAS THE STUDY CONDUCTED?
This study used data from the SLICC cohort. Data were collected at enrolment and then once every year and entered in a central database. At each annual visit, disease activity, damage accrual, medications, and their average doses were recorded. The authors used information from this database to work out the proportion of times that people were in a specific state at each visit since entry into the study.
Overall, five specific disease activity states were defined:
1. Remission off-treatment: defined as having a clinical Systemic Lupus Erythematosus Disease Activity Index (cSLEDAI)-2K score of 0, without taking prednisone or immunosuppressants
2. Remission on-treatment: cSLEDAI-2K score of 0, while taking up to 5 mg per day of prednisone and/ or maintenance immunosuppressant
3. Low disease activity (LDA): cSLEDAI-2K score of 2 or less, without prednisone or immunosuppressants (in line with the Toronto cohort definition)
4. Modified lupus low disease activity (LLDAS): SLEDAI-2K score of 4 with no activity in major organs or systems – and no new disease activity – whilst taking up to 7.5 mg per day of prednisone and/or maintenance immunosuppressants
5. Active disease.
WHAT WERE THE MAIN FINDINGS OF THE REVIEW?
The main finding was that remission off-treatment occurred in 20.9% of the visits, and remission on-treatment in 19.8% of the visits. Excluding remission, LDA was found in in 4.5% of visits, and LLDAS in 5.6% of the visits. People still recorded active disease in 49.2% of visits. The authors found that all four measures of remission or LDA were independently associated with a lower probability of damage, both globally and in specific domains.
ARE THESE FINDINGS NEW?
Yes. This is the first study to evaluate the independent impact of these states on damage accrual. Additionally, this is the most diverse cohort reporting remission and LDA rates.
WHAT ARE THE LIMITATIONS OF THE STUDY?
The main limitation was that it was not possible to use the original definition of remission and LLDAS because the cohort did not record some of the necessary information. Additionally, visits were performed annually, which means it is possible that the study might have missed some disease activity fluctuations that happened between visits.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The authors are evaluating the factors predictive of these different states as well as their impact on costs. They believe that remission and LDA definitions should allow adequate differentiation between these states.
WHAT DOES THIS MEAN FOR ME?
If you have Lupus, your healthcare team will use a target which lets them know if you have achieved a good enough response to treatment to prevent long-term damage building up – and therefore to achieve a good ther- apeutic outcome. These targets are still a work in progress, and you may hear different terms used. If you have any concerns about your disease or its treatment, you should speak to your doctor.
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Date prepared: October 2022
Summary based on research article published on: 9 August 2022
From: Ugarte-Gil MF, et al. Remission and low disease activity (LDA) prevent damage accrual in patients with systemic lupus erythematosus: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis 2021;81(11):1541–1548. doi:10.1136/ard-2022-222487
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