SYSTEMIC LUPUS ERYTHEMATOSUS.

Ann Rheum Dis 2014;73:958-967 doi:10.1136/annrheumdis-2013-205139.

Recommendation
Treat-to-target in systemic lupus erythematosus: recommendations from an international task force
1. Published Online First 16 April 2014

Abstract

The principle of treating-to-target has been successfully applied to many diseases outside rheumatology and more recently to rheumatoid arthritis
. Identifying appropriate therapeutic targets and pursuing these systematically has led to improved care for patients with these diseases and useful guidance for healthcare providers and administrators.

Thus, an initiative to evaluate possible therapeutic targets and develop treat-to-target guidance was believed to be highly appropriate in the management of systemic lupus erythematosus (SLE) patients as well. Specialists in rheumatology, nephrology, dermatology, internal medicine and clinical immunology, and a patient representative, contributed to this initiative.
The majority convened on three occasions in 2012–2013.

Twelve topics of critical importance were identified and a systematic literature review was performed. The results were condensed and reformulated as recommendations, discussed, modified and voted upon. The finalised bullet points were analysed for degree of agreement among the task force. The Oxford Centre level of evidence (LoE, corresponding to the research questions) and grade of recommendation (GoR) were determined for each recommendation.

The 12 systematic literature searches and their summaries led to 11 recommendations. Prominent features of these recommendations are targeting remission, preventing damage and improving quality of life. LoE and GoR of the recommendations were variable but agreement was >0.9 in each case.

. An extensive research agenda was identified, and four overarching principles were also agreed upon.

. Treat-to-target-in-SLE (T2T/SLE) recommendations were developed by a large task force of multispecialty experts and a patient representative. It is anticipated that ‘treating-to-target’ can and will be applicable to the care of patients with SLE..

Treat-to-target in systemic lupus erythematosus: overarching principles and bullet points.

Overarching principle 1: The management of systemic lupus erythematosus (SLE) should be based on shared decisions between the informed patient and her/his physician(s).

Overarching principle 2: Treatment of SLE should aim at ensuring long-term survival, preventing organ damage, and optimising health-related quality-of-life, by controlling disease activity and minimising comorbidities and drug toxicity.

Overarching principle 3: The management of SLE requires an understanding of its many aspects and manifestations, which may have to be targeted in a multidisciplinary manner.

Overarching principle 4: Patients with SLE need regular long-term monitoring and review and/or adjustment of therapy.

Recommendations:

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

2. Prevention of flares (especially severe flares) is a realistic target in SLE and should be a therapeutic goal.

3. It is not recommended that the treatment in clinically asymptomatic patients be escalated based solely on stable or persistent serological activity.

4. Since damage predicts subsequent damage and death, prevention of damage accrual should be a major therapeutic goal in SLE.

5. Factors negatively influencing health-related quality of life (HRQOL), such as fatigue, pain and depression should be addressed, in addition to control of disease activity and prevention of damage.

6. Early recognition and treatment of renal involvement in lupus patients is strongly recommended.

7. For lupus nephritis, following induction therapy, at least 3 years of immunosuppressive maintenance treatment is recommended to optimise outcomes.

8. Lupus maintenance treatment should aim for the lowest glucocorticoid dosage needed to control disease, and if possible, glucocorticoids should be withdrawn completely.
9. Prevention and treatment of antiphospholipid syndrome (APS)-related morbidity should be a therapeutic goal in SLE; therapeutic recommendations do not differ from those in primary APS.

10. Irrespective of the use of other treatments, serious consideration should be given to the use of antimalarials.

11. Relevant therapies adjunctive to any immunomodulation should be considered to control comorbidity in SLE patients.

Dr G Mohan.