Predictors of Remission, Low Disease Activity State Identified in SLE

In patients with systemic lupus erythematosus (SLE), older age predicted a low disease activity state (LDAS) at follow-up, whereas immunosuppressive drug use, LDA shortly after disease onset, and absence of renal, mucocutaneous, or hematologic involvement predicted remission, according to a study published in The Journal of Rheumatology.

A treat-to-target strategy in SLE requires elucidation of the proper targets and timeframes. Achieving either remission or LDAS offers various protective benefits to patients, making both useful therapeutic targets important for disease management. Investigators sought to identify clinical correlates of LDAS or remission in SLE.

The GLADEL trial was a multicenter observational inception cohort study that began in 1997 and was conducted throughout Latin America. The Systemic Lupus Disease Activity Index (SLEDAI) was used semiannually to determine disease activity states, and antimalarial therapy was permitted. The 3 categories of disease activity were: remission (SLEDAI=0 and prednisone≤5 mg/d), LDAS (SLEDAI≤4 and prednisone≤7.5 mg/day), and nonoptimally controlled (SLEDAI>4 and/or prednisone>7.5 mg/d).

Only participants with ≥2 SLEDAI scores with nonoptimally controlled disease activity at baseline were included in the secondary analysis of GLADEL. Primary outcomes at follow-up were remission and LDAS. Multivariable Cox regression analysis was performed to calculate hazard ratios (HRs).

There were 902 nonoptimally controlled patients included in the analysis (89.7% women; median age at diagnosis, 26 years; median SLEDAI at baseline, 10; median follow-up time, 56.3 months). A total of 196 (21.7%) and 314 (34.8%) had achieved remission and LDAS, respectively, at follow-up. Among the 196 participants achieving remission, 97 (49.5%) were followed ≥3 years past remission, of whom 47 (48.5%) attained prolonged remission. Of the 314 who reached LDAS, 164 (52.2%) were followed ≥3 years, of whom 92 (56.1%) had prolonged LDAS.

Remission was associated with lower baseline SLEDAI score (HR, 1.028; 95% CI, 1.006-1.051; P =.0112), immunosuppressive medication use before baseline (HR, 1.468; 95% CI, 1.025-2.105; P =.0364), and lack of renal (HR, 1.487; 95% CI, 1.067-2.073; P =.0191), mucocutaneous (HR, 1.571; 95% CI, 1.064-2.320; P =.0230), or hematologic (HR, 1.354; 95% CI, 1.005-1.825; P =.0463) involvement. Participants achieving remission were more highly educated (P =.0095), with higher socioeconomic status (P =.0030).

A state of LDAS was associated with lower baseline SLEDAI score (HR, 1.025; 95% CI, 1.009-1.042; P =.0027), older age at baseline (HR, 1.050; 95% CI, 1.004-1.098; P =.0341), and lack of renal (HR, 1.344; 95% CI, 1.049-1.721; P =.0194) or mucocutaneous (HR, 1.401; 95% CI, 1.016-1.930; P =.0394) involvement. Those who met LDAS criteria had higher educational attainment (P =.0073) and socioeconomic status (P =.0099).

Study limitations included a low proportion of participants achieving remission off therapy, brief and variable follow-up periods, and a lack of definition uniformity for remission and LDAS.

“Despite these limitations, our data…emphasize the positive impact of not having mucocutaneous, renal and hematologic involvement, of an early use of immunosuppressive drugs and of experiencing lower disease activity early in the course of the disease on a higher likelihood of achieving remission or LDAS,” the authors noted.

Reference

Ugarte-Gil MF, Wojdyla D, Pons-Estel GJ, et al. Predictors of remission and low disease activity state in systemic lupus erythematosus: data from a multi-ethnic, multinational Latin-American lupus cohort [published online March 1, 2019]. J Rheumatol. doi: 10.3899/jrheum.180433