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Found 49 results

  1. APRIL 2019 11 April 2019 by Professor Graham R V Hughes MD FRCP Easter comes late this year. Frenetic Brexit politics – the Westminster establishment fighting to overturn the ‘popular vote’. So sad. Last week I gave a lecture at an ‘immuno-therapy’ meeting in Madrid. Three hundred attendees, including representatives of the Spanish patients’ APS Society. The atmosphere was fantastic. So many doctors (and patients’) wanting to learn more about our syndrome. Talking about ‘learning more’, we now have a date for our own Patients’ Meeting – Friday, 13th September 2019. (For details of the programme and admission, please visit our website: www.ghic.world). This year we are opening up the meeting to include topics on Sjogren’s and lupus, as well as antiphospholipid syndrome. I will also send this blog, as well as details or our annual Patients’ Meeting, to our colleagues in Spain. Patient of the Month “I still feel tired all the time”. Mrs J.S. aged 55, was referred by her G.P. complaining of a variety of symptoms, including aches and pains, headaches, constipation, pins and needles and mental sluggishness. Above all else, she felt constantly fatigued. Despite this very full set of symptoms, the diagnosis remained uncertain. The pins and needles in both hands were put down to carpal tunnel syndrome. But there was little else to find. In view of the frequent headaches, Mrs J.S. was referred to a neurologist who arranged for further tests, including a brain MRI (which showed two small ‘dot’ lesions – reported as probably not significant. To her credit, the neurologist considered lupus and arranged lupus blood tests among the more routine ones. The tests came back showing a normal blood count. However, the ESR (the guide to inflammation) came back ‘borderline positive’ at 35 (normal under 20). The tests for lupus were essentially negative (anti-DNA negative, ANA ‘weak’ (1 in 80). What is the diagnosis (1)? The penny dropped. Could this be thyroid? Bilateral carpal tunnel syndrome is certainly seen in ‘low thyroid’, and significantly Mrs J.S. had a sister with ‘Hashimotos thyroiditis’ – and underactive thyroid with auto-immune features. As with all her other tests the thyroid blood tests were ‘borderline’. Nevertheless, the fatigue, the constipation, the aches and pains, could all be down to ‘low thyroid’. Following a *‘kerbside consult’, with her endocrinology colleague, she instituted thyroxine treatment. Within 2 months the pins and needles were gone and the mental sluggishness, as well as the constipation, were improving. BUT – the aches and pains and the fatigue remained – as bad as ever. What is the diagnosis (2)? It turned out that Mrs J.S. had suffered a series of miscarriages in her early 20’s and she and her husband remained childless. Could the problems – especially the frequent headaches – be due to Hughes Syndrome? Sure enough the antiphospholipid antibody (aPL) tests were strongly positive – not even ‘borderline’. She was started on clopidogrel (‘Plavix’) – an anti-clotting drug similar to aspirin (Mrs J.S. had previously tried aspirin but found it caused indigestion. Result? An almost immediate lessening of the headaches. And, if anything, a further improvement in her memory problems. BUT: no improvement in the fatigue or the aches and pains. What is the diagnosis (3)? Mrs J.S. was referred to a lupus clinic. Again, the results were similar (‘borderline’ ANA and negative anti-DNA). The lupus clinic doctor had seen this before – possible ‘Sjogren’s syndrome’. And, sure enough, the Shirmer’s test – a simple ‘blotting paper’ eye test was completely dry – a useful and very inexpensive screening test for the dry eyes of Sjogren’s Syndrome. Low dose hydroxychloroquine (Plaquenil) (one a day) was started. Three months later at follow-up clinic, ‘fatigue gone. Aches gone. Back to normal life”. What is this patient teaching us? I often talk of ‘The Big Three’ diseases – Lupus, Sjogren’s and Hughes Syndrome, which can overlap clinically However, the world of auto-immune diseases in which I practice includes another ‘big three’, which frequently go together : Hughes Syndrome, Sjogren’s Syndrome and low thyroid (often, specifically, Hashimoto’s thyroiditis) – three ‘named’ syndromes. Clearly, to miss one or even two of the triad would be an ‘under-treatment’. The three conditions can have similar features. And fortunately, potentially very successful treatment – thyroid, aspirin (or Plavix) and hydroxychloroquine. I call the combination of aspirin and hydroxychloroquine (derived from quinine) my ‘two trees’ – treatment –willow and cinchona. Perhaps the biggest lesson from this patient is that there may be more than one diagnosis causing the problems. PROFESSOR GRAHAM R V HUGHES MD FRCP Head of The London Lupus Centre London Bridge Hospital http://www.ghic.world/blog/april-2019
  2. An Increased Risk of Dementia Possible in Lupus Stephanie Pappas Jul 13, 2016 Neuropsychiatric symptoms have long been known to affect some patients with systemic lupus erythematosus. But now, emerging evidence suggests that lupus patients may be at increased risk of dementia, as well. A retrospective study published in April in the journal Arthritis Care and Research used the Taiwan Longitudinal Health Insurance Database 2005, a random sampling of the 99.9 percent of Taiwanese citizens covered by the country's national health insurance, to compare dementia rates in people with systemic lupus erythematosus to age- and sex-matched patients without the autoimmune disease. The analysis revealed a doubled rate of dementia in SLE patients. There were 357 cases per 100,00 person-years in the lupus cohort, compared with 180 cases per 100,000 person-years in the non-SLE cohort. {Crude hazard ratio 1.92, 95 percent CI, 1.14−3.23, P< 0.001.) Dementia is a condition of gradual decline, while neuropsychiatric SLE usually manifests early in the diagnosis, wrote study author Dr. Yu-Ru Lin of Taipei Medical Hospital and colleagues. Antiphospholipid antibodies might put patients at risk of micro-stroke, they hypothesized. Alternatively, anatomical changes in the brain attributable to the disease or corticosteroid treatments may contribute to cognitive decline. Rheumatology Network spoke with Dr. Yehuda Shoenfeld, an autoimmunity researcher at Tel Aviv University in Israel, for a deeper look at the dementia-lupus connection. Though not involved with the Taiwanese study, Dr. Shoenfeld has conducted research on lupus autoantibodies and has written about neuropsychiatric lupus in the clinic. He provided his perspective on the need to better understand how lupus might affect the brain. RN: Obviously, neurologic symptoms are well-known in systemic lupus erythematosus. What is the difference between central nervous system lupus and dementia? Shoenfeld: There are neurological, physical findings and also X-ray findings in which you see defects in neurological functions, mainly nerves which can be motor or sensory or so forth. It can be represented by conversions. It can be represented by paralysis. It can be presented as paresthesia, which means it feels like ants are going on your body. So it's more in the domain of physical examination. Dementia is more that you lose your capacity for cognition, memory or so forth. You cannot detect it by X-rays, but you can detect it by talking to the patient and listening to him and you can see that he's not finding himself, I would say, in space. So this is a big difference. What is new about this study by Lin and colleagues? So far we knew that CNS lupus is quite common, 20 percent of the patients can suffer from that. There are many manifestations of CNS lupus from paralysis to conversion, from deafness to blindness, from paresthesia to pains and so forth. Dementia up until now was not part of the story of lupus - neither in regular lupus nor in CNS lupus. We did have psychotic attack in CNS lupus, which could be completely resolved upon proper therapy, for instance with corticosteroids or immunosuppressive drugs. Suddenly, there is dementia. Now, I want to remind you that lupus is a disease of young females, so it's not elderly females with dementia at this age. So the people who published the paper came with the idea that in those patients with CNS lupus, you can find, eventually, more dementia, which is a new revelation, not known so far. With my colleague, Professor Howard Amital [of Sheba Medical Center], an expert on Big Data — we asked the computer to cross the word dementia with SLE in a health database, but we did something else in this respect. We compared it to two other autoimmune diseases. I have to say that, to my great surprise, we have found also that patients with SLE have a threefold increase in dementia. We were not able so far to segregate it to the different factor that we would like to, but we found also with rheumatoid, there was an increase. There was no increase, for instance, in Behcet's syndrome. So most probably, these results are correct, and they should raise a red light. We will analyze our results and we will publish it very soon. But I think it's interesting, even though I had not believed this when I had received the paper from you. What kind of mechanisms might explain why there could be this link? When you have an organic damage to the brain, being autoimmune in nature, being the position of autoantibodies, being the position of other factors it causes chronic damage to the brain and eventually, there is some kind expression that above this threshold it can cause the psychological defects which are expressed as dementia. It's like accumulating damage. Given what is known right now, what is the message for practicing rheumatologists? Before we do anything with patients, we should confirm the results and indeed analyze what could be the mechanism and then eventually work on this to see how we could prevent this. Maybe, for instance, a very quick recovery should be installed whenever there are any signs of CNS lupus. We have to see if, indeed, it's limited only to patients with CNS lupus. There is a lot to analyze now, to learn, to study and to draw conclusions for the future. References: Lin Y-R, Chou L-C, Chen H-C, Liou T-H, Huang S-W, Lin H-W. "Increased risk of dementia in patients with systemic lupus erythematosus: A nationwide population-based cohort study." Arthritis Care & Research. 2016. doi:10.1002/acr.22914. Kivity S, Agmon-Levin N, Zandman-Goddard G, Chapman J, Shoenfeld Y. "Neuropsychiatric lupus: a mosaic of clinical presentations." BMC Medicine BMC Med. 2015;13(1):43. doi:10.1186/s12916-015-0269-8. https://www.rheumatologynetwork.com/lupus/increased-risk-dementia-possible-lupus
  3. SLE Patients at Higher Risk for Some Blood Cancers, Study Says FEBRUARY 18, 2019 BY JOANA CARVALHO IN NEWS. Click Here to receive Lupus News via e-mail Systemic lupus erythematosus (SLE) patients have a higher risk for certain cancers — including cervical, thyroid, ovarian, and oral cancer, as well as lymphoma, multiple myeloma, and leukemia — than the general population, emphasizing the importance of cancer screening programs as part of SLE management. The findings of the study, “Systemic lupus erythematosus is a risk factor for cancer: a nationwide population-based study in Korea,” were published in Lupus. SLE, the most prevalent form of lupus, is a chronic autoimmune disease characterized by behavioral and psychological symptoms including pain, fatigue, depression, and impaired cognition. Previous studies have suggested that SLE patients are more likely to be affected by certain types of cancers, including non-Hodgkin’s lymphoma, lung, liver, and vaginal cancer. “However, some studies have found a decreased risk of some hormone-sensitive cancers, such as breast, ovarian, and endometrial cancer, in SLE patients. However, whether patients with SLE have increased or decreased risk of breast cancer remains unclear,” the researchers said. In this study, investigators set out to characterize the relationship between SLE and cancer in the entire Korean population. The nationwide, retrospective, cohort study involved 21,016 SLE patients and 105,080 age- and sex-matched controls without SLE. The cohort was selected from the Korean National Health Insurance Service (NHIS) database between 2008 and 2014. Over a follow-up period of seven years, 763 (3.36%) SLE patients and 2,667 (2.54%) controls developed cancer. The incidence risk of cancer was higher in SLE patients compared to controls (6.427 vs 4.466). Incidence risk refers to the chance of a disease happening over a defined period of time. After accounting for age and sex, SLE patients showed a 44% higher risk of developing cancer. No differences in cancer risk were found between female and male SLE patients. SLE patients at higher risk for cancer were younger (under 40) and male, being 12 and 29 times more likely of developing lymphoma than control subjects. Looking at different cancer types, researchers found that SLE patients were more likely to develop cervical, thryoid, ovarian, and oral cancer, as well as lymphoma, leukemia, and multiple myeloma than controls. On the other hand, no significant differences in the risk of stomach, colorectal, liver, pancreatic, lung, breast, prostate, biliary, laryngeal, renal, bladder, nerve, and skin cancer were found between SLE patients and controls. While the mechanisms leading to increased risk of cancer in SLE patients are yet to be fully understood, the findings highlight the need for cancer screening programs among this patient population. “In conclusion, SLE is an independent risk factor for malignancy, especially cervical, thyroid, ovarian, oral … as well as lymphoma, multiple myeloma, and leukemia. The importance of cancer screening programs should be emphasized in SLE patients,” the scientists concluded. https://lupusnewstoday.com/2019/02/18/sle-patients-may-be-at-higher-risk-of-developing-certain-types-of-cancer/?utm_source=LUP+NEws+E-mail+List&amp;utm_campaign=1e70fc3e85-RSS_WEEKLY_EMAIL_CAMPAIGN_US&amp;utm_medium=email&amp;utm_term=0_50dac6e56f-1e70fc3e85-71887989
  4. Congratulations and Many Thanks to Lady Gaga! To the entire world, Lady Gaga is a winner. But to the lupus community she’s a hero. Last night at the 2019 Grammy’s, she won an award for Best Pop Solo in honor of her aunt Joanne who lost her battle with lupus at 19. Afterwards she tweeted: Lady Gaga has shared the song’s significance on social media. “I have carried a deep grief in my heart over my family’s tragedy. The loss of Joanne affected my father so deeply that it affected me. When he cried, I cried. When he was angry, I was angry. When he was hurt, I hurt. Today I transform this grief to hope and healing. After 10 years with you I still get nervous before the Grammys, but I know I have an angel with me.” Hear about lupus research from Lady Gaga's dad And watch this video to hear directly from Lady Gaga’s dad, Joe Germanotta, about why he has honoured his sister by actively supporting the Lupus Research Alliance. As a member of our Board of Directors, Joe believes that the research funded by the Lupus Research Alliance is where hope begins. Where our funded research discoveries are breaking through to deliver better treatments and a cure!
  5. Lupus: 3 Things to Know Mark L. Fuerst Dec 3, 2018 Lupus Three new studies in systemic lupus erythematosus (SLE) reveal that a gut bacterium may be linked to autoimmune diseases, including SLE; pregnancy complications in women with lupus have decreased over the past 2 decades; and physical or emotional abuse in childhood raises the risk of lupus.1-3Scroll through the slides for the latest findings and their clinical implications. http://www.rheumatologynetwork.com/lupus/lupus-3-things-know
  6. Environmental Factors Tied to Lupus Gregory M. Weiss, M.D. Tuesday, December 5, 2017 Lupus Key points • Ultraviolet light may cause flare-ups in systemic lupus erythematosus (SLE). • The chemicals found in cigarette smoke can worsen the symptoms of SLE. • Estrogen analogues such as oral contraceptives and bisphenol A (BPA), a substance used to make plastic bottles, may increase the risk of SLE. Background SLE affects women and African Americans disproportionately. Dr. Gaurav Gulati at the University of Cincinnati in Ohio points out that even though we have treatments for lupus, a complete understanding of its etiology and progression is lacking. Although genetics clearly plays a role in SLE, it appears that environmental factors may act as triggers in those who are susceptible. Dr. Gulati conducted a review of the literature related to SLE and environmental versus genetic factors; he presented his findings recently in Seminars in Arthritis and Rheumatism. The study A systematic review was conducted that looked at over 100 studies focused on SLE. The results • A triad of factors was found in one study that linked a patient’s genetics, how the patient’s DNA changes over time, and exposure to environmental factors to the development and course of SLE. • Twin studies reveal only a 24% concordance of SLE in identical siblings; this points to a conclusion that a combination of genetic predisposition and environmental factors is involved in the development of lupus. • Heavy metals and other trace elements may be triggers for SLE; uranium, lead, and cadmium are linked to autoimmunity. • Elements such as mercury, nickel, and gold have been implicated in delayed hypersensitivity and inflammation, and a higher rate of lupus has been noted among dental workers. • An increase in SLE has been found in women who take oral contraceptives and in those exposed to xenoestrogens such as BPA, a chemical found in plastics. Implications for physicians • Physicians and particularly rheumatologists who treat patients with SLE should vigorously encourage positive lifestyle modifications such as smoking cessation and avoidance of direct sunlight. • Patients with SLE should be advised to always wear sunscreen. • Rheumatologists should provide regular surveillance to their patients with SLE as changes in disease activity and treatment are warranted. References: Gulati G, Brunner HI. Environmental triggers in systemic lupus erythematosus. Semin Arthritis Rheum. 2017 Oct 5. pii: S0049-0172(17)30469-9. doi: 10.1016/j.semarthrit.2017.10.001. [Epub ahead of print]
  7. Sex Differences in Lupus Mortality Mariah Zebrowski Leach, JD, MS Monday, December 4, 2017 A comprehensive US population-based study identified an average 22-year and 12-year deficit in life expectancy among females and males with systemic lupus erythematosus (SLE), respectively, compared with the general population. Background In the United States, SLE is a source of significantly decreased life expectancy. While marked differences have been observed between the sexes in terms of the incidence, prevalence, and clinical manifestations of SLE, this area is still poorly understood. Falasinnu and colleagues1 at Stanford School of Medicine identified sex-based differences in the causes of death among SLE decedents in the United States and recognized clinically relevant comorbidities that may warrant careful consideration in patients’ clinical management. The study This study examined SLE-related deaths using the 2014 National Center for Health Statistics multiple cause of death (MCOD) database, a population-based electronic medical recording of all death certificates issued in the United States. The analysis considered not only the number of death certificates listing SLE as the underlying cause of death, but also those listing SLE in general. Demographic information considered included age, race/ethnicity, sex, educational attainment, foreign-born status, marital status, and pregnancy status. SLE decedents were compared with non-SLE decedents in the general population belonging to the same age group. The findings In 2014, there were 2,660,497 deaths in the United States, of which 2036 (0.1%) listed SLE among the causes of death. Approximately 86.2% of SLE deaths occurred among females, with a median age at death of 59 years and the highest proportion of deaths occurring between 45 and 64 years of age. In comparison, the overall median age at death for females in the general population was 81 years, and the majority of deaths occurred among females over 65 years of age. Black females experienced the greatest burden of SLE mortality. Approximately 32% of all female SLE decedents were black, compared with only 11% of non–SLE-related deaths in the general population. Female decedents with SLE had a slightly higher proportion of foreign-born individuals than the general population, but there were no other significant demographic differences. The most frequently listed comorbidities among female decedents with SLE were septicemia (4.32%) and hypertension (3.04%). Among male decedents with SLE, the median age at death was 61 years, compared with 73 years in the general population. Of male decedents with SLE, 23.5% were black, compared with only 12% in the general population. The age-standardized mortality was highest among American Indian males. There were no other demographic differences related to SLE among male decedents. The most frequently listed comorbidities among male decedents with SLE were heart disease (3.70%) and diabetes mellitus with complications (3.61%). Implications for physicians and future research This study offers an opportunity to better describe the association between SLE and related comorbidities in the context of mortality, although the MCOD data have a number of limitations. Inaccuracy on death certificates can lead to the underestimation of the SLE mortality burden, and researchers were unable to differentiate between causes of death that were related to the natural age process, disease activity, and drug therapy. Still, the MCOD data provide a comprehensive understanding of the population-based burden of SLE mortality. While female SLE patients tend to have more frequent disease exacerbations, male patients appear to have significantly greater multisystemic damage accrual and disease severity. Greater disease severity among male SLE patients may be related to under diagnosis due to selective attention given to females by physicians during clinical decision-making. This potential for gender bias needs to be carefully considered. Racial minorities generally have a disproportionately higher burden of mortality. The scope and degree of these differences in SLE are particularly pronounced, with mortality rates among black females nearly four times as high as those in white females. “Our findings reinforce the urgent need for interventions that reduce morbidity and mortality in patients with SLE to improve health outcomes and ultimately reduce health disparities,” the researchers write. They note that novel translational research programs are currently underway to attempt to address these disparities. Clinically relevant comorbidities also need to be considered more carefully in the course of patients’ clinical management and the natural history of SLE. This study revealed future targets for the investigation of sex-based differences and directions for epidemiological research. “A comprehensive understanding of causes of death and the related comorbidities can improve clinical diagnostic and therapeutic strategies, impact survival outcomes in patients living with SLE, and enhance population-based disease surveillance estimates,” the researchers conclude. References: 1. Falasinnu T, Chaichian Y, Simard JF. Impact of sex on systemic lupus erythematosus-related causes of premature mortality in the United States. J Womens Health (Larchmt). 2017;26:1214-1221. doi: 10.1089/jwh.2017.6334.
  8. Treatment Target Shows Promise in Systemic Lupus Erythematosus Mariah Zebrowski Leach, JD, MS Monday, December 4, 2017 The lupus low disease activity state (LLDAS) is a promising treatment target in systemic lupus erythematosus (SLE), according to new research. Background Successfully applied in rheumatoid arthritis as well as in non-rheumatic conditions, a treat-to-target approach aims to improve disease outcomes through the achievement of a pre-specified goal. An international task force suggested such a strategy for the treatment of SLE.1 They recommended that the treatment target should be remission or—when that is unachievable—the lowest possible disease activity. LLDAS is a composite definition of minimal acceptable disease activity proposed by the Asia-Pacific Lupus Collaboration (APLC). LLDAS is based on the following criteria: 1. SLE Disease Activity Index 2000 (SLEDAI-2K) ≤ 4, with no activity in major organ systems 2. No new lupus disease activity compared with the previous assessment 3. Safety of Estrogen in Lupus Erythematosus National Assessment (SELENA)-SLEDAI physician global assessment (PGA) ≤ 1 4. Current prednisolone (or equivalent) dose ≤ 7.5 mg daily 5. Well-tolerated standard maintenance doses of immunosuppressive drugs and approved biological agents To be considered a valid treatment target, LLDAS should be protective against damage accrual in the early SLE stages. Piga and colleagues2 at the University Clinic and AOU of Cagliari in Italy sought to determine the frequency of LLDAS achievement and its association with early damage accrual in a homogenous cohort of Caucasian patients with SLE prospectively assessed during the first 18 months of treatment after diagnosis. The study This study primarily aimed to assess the frequency of LLDAS achievement and its association with early damage, with a secondary aim to identify the main reasons for failure to achieve LLDAS. The study cohort consisted of 107 patients from the Cagliari (Italy) SLE cohort between January 2006 and December 2016. To assess LLDAS as a goal for initial treatment, the primary study endpoint was set at 6 months, with 18 months considered an appropriate time to evaluate the effect of maintenance treatment and early damage accrual. At each visit, disease activity was assessed using the SLEDAI-2K score and the PGA. At 18 months, damage accrual was assessed by the SDI and the possible attribution to corticosteroids was done according to a previous definition. Average daily dose of prednisolone (or equivalent) and ongoing use and new prescription of medications were assessed at every visit. The findings At the 6-month point, LLDAS had been achieved by 47 patients (43.9%). At 18 months, 48 patients (44.9%) were in LLDAS; 33 of them had achieved LLDAS at 6 months and were still in this condition and 15 had reached LLDAS for the first time. Of the 59 patients who were not in LLDAS at 18 months, 45 had never been in LLDAS and 14 had been in LLDAS at 6 months but no longer were at 18 months. Thus, despite a seemingly overall stable LLDAS rate, these results demonstrate the dynamic nature of this condition. On univariate analysis, the following factors were significantly associated with failure to achieve LLDAS at 6 months: renal involvement, higher SLEDAI-2K score, positive (> 10 UL/mL) anti-dsDNA antibodies, lower serum C3 and C4 values, and higher prednisolone dose and immunosuppressant drug use. On multivariate analysis, renal involvement and C4 levels were confirmed to be associated with failure to achieve LLDAS. Implications for physicians The limitations of this study are the relatively small sample size, which may have hampered study results, and the retrospective design, which prevented researchers from testing LLDAS criterion validity by comparing it with other treatment targets such as the SLE Responder Index. Nevertheless, by enrolling consecutively diagnosed patients at the time of treatment initiation and following them prospectively, the researchers were able to provide novel data on LLDAS as a potential treatment target. In this study, the most frequent reason for failure to achieve LLDAS 6 months after therapy initiation was daily prednisolone dosage > 7.5 mg. Damage was definitely attributable to steroid use in 40% of cases in this cohort. However, supported by this data and literature evidence on damage development, the researchers consider 7.5 mg/d an acceptable cutoff to define low disease activity during initial treatment. Still, they recommend a lower cutoff should be targeted to minimize risk of steroid-related damage during maintenance therapy in patients with SLE. In this cohort, patients with renal involvement and serological disorders had the lowest remission rate, and renal involvement at baseline was the most important factor associated with failure to achieve LLDAS. “LLDAS is a promising treatment target in SLE, being attainable and negatively associated with damage accrual in the early stages of the disease,” the researchers write. “However, it seems to poorly fit with the heterogeneity of clinical presentation in patients with SLE, mostly in those with renal involvement,” they conclude. References: 1. van Vollenhoven R, Voskuyl A, Bertsias G, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis. 2014;73:958-967. 2. Piga M, Floris A, Cappellazzo G, et al. Failure to achieve lupus low disease activity state (LLDAS) six months after diagnosis is associated with early damage accrual in Caucasian patients with systemic lupus erythematosus. Arthritis Res Ther. 2017;19:247. doi: 10.1186/s13075-017-1451-5.
  9. Poverty Stacks the Deck Against Patients With Lupus Gregory M. Weiss, M.D. Tuesday, November 28, 2017 Lupus Poor patients with systemic lupus erythematosus (SLE) who receive Medicaid are less likely to adhere to their treatment regimen than are patients who live in more affluent areas. Adherence to SLE therapy may also be lower in areas with large African American populations and limited access to health care professionals. In addition, Medicaid patients are less likely to take hydroxychloroquine for lupus if they live in areas with fewer hospitals, high African American populations, and low provider numbers. SLE strikes women with greater frequency than men and is more than twice as common in the African American population. Dr. Candace Feldman and colleagues at Harvard Medical School note that compliance with hydroxychloroquine therapy in lupus patients is poor at baseline. “Studies in other chronic diseases demonstrate that where individuals live has a significant effect on their health-related behaviors and on disease control and outcomes,” said Dr. Feldman. It was this premise that led the authors to look into how location and resources contribute to adherence to treatment in SLE. They presented their findings at the recent American College of Rheumatologyannual meeting in San Diego, California. The study Utilizing the Medicaid database, new users of hydroxychloroquine were identified and adherence was measured over a 12-month period. The study included 10,268 subjects with SLE who were new users of hydroxychloroquine. The results • Only 15% of subjects remained adherent to hydroxychloroquine therapy based on taking the drug on 80% or more of days covered. • Zip codes with higher percentages of African American residents had lower odds of adherence. • Adherence was highest in counties with more hospitals and lowest in areas with low numbers of health care professionals. • Living in areas with higher numbers of African Americans and fewer hospitals and health care professionals independently predicted low adherence to hydroxychloroquine therapy. Implications for physicians • Low adherence to hydroxychloroquine therapy in SLE is widespread among Medicaid recipients. • Patients with SLE in predominantly low-income, African American communities are at higher risk for non-compliance to hydroxychloroquine therapy. • Lack of access to health care providers and hospitals reduces the likelihood that patients with lupus will adhere to therapy. • Physicians should make every effort to identify barriers to care and treatment adherence, especially in low-income patients with lupus who live in isolated communities with large minority populations. References: American College of Rheumatology Press Release. “Diversity Rate and Poor Access to Health Professionals May Influence Lupus Therapy Adherence.” November 4, 2017. ACR/ARHP Annual Meeting. San Diego, California.
  10. An evidence-based approach to pre-pregnancy counselling for patients with systemic lupus Y K Onno Teng Edwin O W Bredewold Ton J Rabelink Tom W J HuizingaH C Jeroen Eikenboom Maarten Limper Ruth D E Fritsch-StorkKitty W M Bloemenkamp Marieke Sueters Rheumatology, kex374, https://doi.org/10.1093/rheumatology/kex374 Published: 20 November 2017 Abstract Patients with SLE are often young females of childbearing age and a pregnancy wish in this patient group is common. However, SLE patients are at high risk for adverse pregnancy outcomes that require adequate guidance. It is widely acknowledged that pre-pregnancy counselling is the pivotal first step in the management of SLE patients with a wish to become pregnant. Next, management of these patients is usually multidisciplinary and often requires specific expertise from the different physicians involved. Very recently a EULAR recommendation was published emphasizing the need for adequate preconception counselling and risk stratification. Therefore the present review specifically addresses the issue of pre-pregnancy counselling for SLE patients with an evidence-based approach. The review summarizes data retrieved from recently published, high-quality cohort studies that have contributed to a better understanding and estimation of pregnancy-related risks for SLE patients. The present review categorizes risks from a patient-oriented point of view, that is, the influence of pregnancy on SLE, of SLE on pregnancy, of SLE on the foetus/neonate and of SLE-related medication. Lastly, pre-pregnancy counselling of SLE patients with additional secondary APS is reviewed. Collectively these data can guide clinicians to formulate appropriate preventive strategies and patient-tailored monitoring plans during pre-pregnancy counselling of SLE patients. https://academic.oup.com/rheumatology/advance-article-abstract/doi/10.1093/rheumatology/kex374/4641853?redirectedFrom=fulltext
  11. 21 November, 2017 SAN DIEGO — At the American College of Rheumatology Annual Meeting, Joan Merrill, MD, spoke about a study that she said is further demonstration that atacicept should continue being developed as a potential treatment for lupus. According to Merrill, the results also suggest that measurements of low-disease activity may represent not just clinically meaningful endpoints, but may also “work as endpoints in clinical trials to discriminate drug from placebo.” https://www.healio.com/rheumatology/lupus/news/online/{1b289264-6a9b-47a3-86c6-9b0eb8a3980f}/video-atacicept-is-a-potential-exciting-treatment-for-lupus?utm_source=selligent&utm_medium=email&utm_campaign=rheumatology news&m_bt=1879111151405
  12. Obesity linked to worse outcomes of pain, fatigue, depression in women with lupus November 13, 2017 SAN DIEGO — Among women with systemic lupus erythematosus, obesity appears to be independently linked to worse patient-reported outcomes, suggesting that weight loss may improve outcomes for this population, according to findings presented at the American College of Rheumatology Annual Meeting. “The research that I am presenting at this conference was inspired by previous work that showed that patients with lupus experienced big deferments in patient-reported outcomes, or PROs,” Sarah L. Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and an author of the study, said in her presentation. “It's also been noted that these deferments in PROs are not fully explained by the severity of their lupus disease or by sociodemographic factors such as poverty. So, we therefore wanted to know whether body composition and, specifically, excess adipose tissue contributes to the worse health-related quality of life and greater symptom burden that we see in this particular patient population.” In the study, Patterson and colleagues identified a sample of 148 patients with SLE (65% white, 14% Asian and 13% African-American; mean age, 48 ± 12.3 years) from the Arthritis Body Composition and Disability (ABCD) study. Eligible participants were women aged at least 18 years who had a diagnosis of SLE that could be corroborated by medical record review. The researchers calculated BMI and fat mass index (FMI). FMI measures total fat mass adjusted for height and was evaluated in the study using whole dual-energy X-ray absorptiometry. Obesity was defined using two designations: FMI of at least 13 kg/m2 and BMI of at least 30 kg/m2. The following four validated patient-reported outcomes were included as dependent variables: disease activity via Systemic Lupus Activity Questionnaire, depressive symptoms via Center for Epidemiologic Studies Depression Scale, pain assessed by SF-36 pain subscale and fatigue measured by SF-36 vitality subscale. Multivariable linear regression was used to analyze correlations of obesity with patient-reported outcomes , adjusted for possible confounding factor (age, race, education, income, smoking status, disease duration, disease damage and prednisone use). Adjusted means for each outcome were then calculated based on the multivariable regression. Of the patients in the sample, 17% had poverty-level income; 86% had education beyond high school; the mean duration of disease was 16 ± 9 years; and 45% were being treated with glucocorticoids. Based on the FMI definition of obesity, 32% of patients met the criteria for obesity, whereas 30% were deemed obese by the BMI definition. The multivariate regression model found that FMI-defined obesity was correlated with worse scores on each patient-reported outcome (greater disease activity, higher levels of depression, more pain and more fatigue). In the analyses that used the traditional BMI of at least 30 kg/m2 criteria, the same correlations were seen between obesity and each of the patient-reported outcomes. “These findings have important clinical implications. The PROs that we measured, particularly pain and fatigue, are known to have profound effects on quality of life, and remain a major area of unmet need in people with lupus,” Patterson said. “In other words, there are many patients with lupus who are treated with aggressive immunomodulatory therapy and these symptoms of pain and fatigue persist. The relationship that we observed between excess fat and worse outcomes really underscores the need for lifestyle interventions for lupus patients who are overweight.” – by Jennifer Byrne Reference: Patterson SL, et al. Abstract #2263. Presented at: American College of Rheumatology Annual Meeting; Nov. 4-8, 2017; San Diego. Disclosures: The authors report no relevant financial disclosures. https://www.healio.com/rheumatology/lupus/news/online/{88b88835-9c84-4880-a058-1e4d1d926aa6}/obesity-linked-to-worse-outcomes-of-pain-fatigue-depression-in-women-with-lupus?utm_source=selligent&utm_medium=email&utm_campaign=rheumatology news&m_bt=1879111151405
  13. Lupus Survival Much Improved, But Plateaued September 25, 2017 | Lupus By Gregory M. Weiss, M.D. Survival rates for patients with systemic lupus erythematosus have plateaued since the middle of the 1990s after a period of major improvement starting in the 1950s. It has been thought that survival in systemic lupus erythematosus has continued to improve over the years, with reports of survival in adults increasing from 50% in the 1950s to more than 95% in the 1990s. Data with regard to survival trends in low- and middle-income countries and at 10- and 15-year periods are limited, so Maria Tektonidou and fellow researchers in Greece sought to describe mortality trends for children and adults with systemic lupus erythematosus and presented their findings in a recent Annals of the Rheumatic Diseases article. The study The authors performed a systematic review of the literature, looking at children and adults with systemic lupus erythematosus. Ultimately included in the final analysis were 171 studies; 125 looked at adult survival rates, 51 at pediatric survival, and 5 at both. Results • Studies in high-income countries showed a steady increase in survival from the middle of the 1950s to 1990. Survival rates have remained stable since then. • Five-year survival in high-income countries is greater than 95% in both adults and children who have systemic lupus erythematosus. • Five- and 10 year survival was lower for children than adults in low- to middle-income countries. Adults • Survival in adults with systemic lupus erythematosus has not continued to improve through the 2000s. • From 2008 to 2016, survival rates for adults with systemic lupus erythematosus in high-income countries at 5, 10, and 15 years were 0.95, 0.89, and 0.82, respectively (95% confidence intervals [CIs], 0.94-0.96, 0.88-0.90, and 0.81-0.83, respectively). • From 2008 to 2016, survival rates for adults with systemic lupus erythematosus in low- to middle-income countries at 5, 10, and 15 years were 0.92, 0.85, and 0.79, respectively (95% CIs, 0.91-0.93, 0.84-0.87, and 0.78-0.81, respectively). Children • From 2008 to 2016, survival rates for children with systemic lupus erythematosus in high-income countries at 5 and 10 years were 0.99 and 0.97, respectively (95% CIs, 0.98-1.0 and 0.96-0.98, respectively). • From 1980 to 2000, survival rates for children with systemic lupus erythematosus in low- to middle-income countries at 5 and 10 years were 0.85 and 0.79, respectively (95% CIs, 0.83-0.88 and 0.76-0.82, respectively). • Listing of systemic lupus erythematosus as the cause of death in all cohorts decreased over time. Implications for physicians • Although survival in adults and children with systemic lupus erythematosus both in high-income and in low/middle-income countries has improved dramatically since the 1950s, further gains have not been realized in the 2000s. • A decreased frequency of deaths attributed to systemic lupus erythematosus may be the result of new immunosuppressive drugs and combination therapies. • No increase in death resulting from cardiovascular events or cancer was seen in adults with systemic lupus erythematosus. • The authors suggested that strides need to be made in determining why survival rates are lower in children than in adults in low- and middle-income countries. http://www.rheumatologynetwork.com/lupus/lupus-survival-much-improved-plateaued?GUID=&rememberme=1&ts=26092017
  14. Women with Lupus Overwhelmingly Have Healthy Pregnancies By Whitney L. Jackson In contradiction to long-standing beliefs, a healthy pregnancy is possible for women who have lupus, says Jill Buyon, M.D., a rheumatologist and lupus specialist from New York University School of Medicine. “Patients with lupus have been under the impression that pregnancy would be a very dangerous thing for them. From the mother’s perspective, the concerns are: Will the mother sustain a lupus flare? For mothers who have once had kidney involvement: How safe is it to get pregnant? Will there be adverse pregnancy outcomes? Will the baby be very small? Will the baby be born so early that it needs to be in the hospital for a long time. And, of course, the scary question is: Will my baby die? These are the outcomes we look at from the perspective of counseling and what we wanted to learn from this study,” she said. Dr. Buyon recently published research in the Annals of Internal Medicine showing that women with relatively inactive lupus without serious flares experienced a normal pregnancy with a positive outcome. Study participants were women, ages 18-to-45, enrolled in the Predictors of Pregnancy Outcome: Biomarker in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus (PROMISSE) Trial. The investigation was multi-center, multi-racial and multi-ethnic. Out of the 385 women followed during the study, 81 percent experienced no adverse events. Overall, 9 percent of pregnancies resulted in premature birth, 4 percent experienced pregnancy loss during the second or third trimester, 1 percent encountered infant death due to pregnancy complications, and 10 percent had very low birth weight. Throughout the study, investigators identified four factors that appeared to increase a woman's likelihood for a negative outcome — high blood pressure during pregnancy, more active lupus during gestation, low platelet count, and a positive lupus anticoagulant test during the first trimester. “The patients who tended to be more sick at the outset, tended to be those who might have an adverse pregnancy outcome. The highest risk factor is the presence of something called a lupus anticoagulant. The presence of this abnormal blood test is very important and one that absolutely all doctors should test for,” Dr. Buyon said. In addition, race and ethnicity — black, Hispanic and Asian — contributed to poor outcomes and was in and of itself, a risk factor. Dr. Buyon said she doubts it is due to socioeconomic factors because the patients were treated by similar doctors in tertiary care centers. She suspects it may be due to genetics, which needs to be explored. Although the findings point to the possibility of healthy pregnancies for this population, Dr. Buyon cautioned women who have high protein levels in urine due to uncontrolled kidney disease could still face significant problems with pregnancy. These women are typically advised to postpone pregnancy until their kidney disease improves. Ten to 15 percent of patients had a moderate flare requiring minimal medication changes, but less than 5 percent of patients had a flare that required high dose steroids or hospitalization. About one in five patients had a renal flare. “The other optimistic perspective was that 225 patients never had kidney disease, but many of them had anti DNA antibodies which is an antibody we worry about in developing renal disease. Only four people developed de novo renal disease. For people who had previous kidney disease ... but were in complete remission, they too had very few renal flares. I think this is very encouraging news for women with past renal disease who really are so worried that maybe they’ll never have a healthy pregnancy, that simply is not true (14:01),” Dr. Buyon said. The hope, she said, is that these findings can be used to inform discussions between doctors and their patients with lupus who are also interested in pursuing pregnancy. Dr. Buyon discusses the study, its findings and implications in the following video with Rheumatology Network. REFERENCES Jill P. Buyon, MD; Mimi Y. Kim, ScD; Marta M. Guerra, MS, et al. "Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study," Annals of Internal Medicine, Aug. 4, 2015. DOI: 10.7326/M14-2235 http://www.rheumatologynetwork.com/lupus/women-lupus-overwhelmingly-have-healthy-pregnancies?GUID=&rememberme=1&ts=12092017
  15. Selena Gomez reveals kidney transplant, best friend was donor FROM THE TOPICENTERTAINMENT 14/09/17 Selena Gomez has revealed that she had a kidney transplant operation this summer linked to her lupus. In an Instagram post, the singer says that her friend Francia Raisa donated an organ to her and says she wanted to explain why fans hadn't heard much from her despite having new music out. "So I found out I needed to get a kidney transplant due to my Lupus and was recovering," she writes. "It was what I needed to do for my overall health." Image captionSelena Gomez has also posted photos of her scar from the kidney transplant operation Selena Gomez also thanked her friend, The Secret Life of the American Teenager actress Francia Raisa, in her Instagram post. Morerelated stories Selena Gomez: Social media isn't real life When celebrities go out in disguise Selena Gomez had lupus but what is it? "There aren't words to describe how I can possibly thank my beautiful friend Francia Raisa," she writes. "She gave me the ultimate gift and sacrifice by donating her kidney to me. I am incredibly blessed. I love you so much sis." Image captionSelena Gomez helped her friend Francia Raisa out in 2014 at the Annual Unlikely Heroes awards in LA, which she was hosting Selena Gomez released the first single from her new untitled album, It Ain't Me featuring Kygo, in March. Since then Bad Liar and Fetish have come out but she hasn't been out promoting the tracks because of her operation. Her first public appearance after recovering from the surgery was in New York with boyfriend The Weeknd last Friday night. She also took time off social media last year to deal with panic attacks, anxiety and depression. The 25-year-old says her ongoing mental health problems are a side-effect of her lupus diagnosis last year. Image captionSelena Gomez appeared in Radio 1's Live Lounge in 2015 to promote her album, Revival Lupus affects the body's immune system. The symptoms of the disease include extreme tiredness, rashes (especially on the face, wrists and hands), joint pain and swelling. In her post, she says not enough is known about the condition. "Lupus continues to be very misunderstood but progress is being made." Find us on Instagram at BBCNewsbeat and follow us on Snapchat, search for bbc_newsbeat http://www.bbc.co.uk/newsbeat/article/41268256/selena-gomez-reveals-kidney-transplant-best-friend-was-donor
  16. 6 of the Best Apps for Chronic Illness Management JULY 17, 2017 BY WENDY HENDERSON IN SOCIAL CLIPS. Click Here to receive Lupus News via e-mail Managing a chronic illness can be difficult. There are many different medications to take (often at different times), appointments to remember, symptoms to keep track of, and lots of information to absorb. Thankfully, living in a digital age means that there are numerous mobile apps that can help you manage your chronic illness. We’ve put together a list of some of the best mobile apps for managing your chronic illness: Medisafe is an app that helps patients manage medications. It helps with dosage and reminds you when you need to take your meds, increasing adherence rates. The information can also be shared with your healthcare team and pharmacy. Pain Diary works for anyone with a chronic illness. It allows patients to chart and score pain as well as record and track other symptoms of the disease such as fatigue and mood swings. This app also has a feature where patients can connect with others living with the same chronic illness and swap best practices. ZocDoc is a handy app if you’ve recently been diagnosed with a chronic illness, since one of the first things you’ll need to do is find a doctor to treat you. ZocDoc allows you to search for local specialist doctors who are approved by your insurance company. The app will even tell you when the doctor is available to see you. MORE: Nine important facts about lupus you may not know. My Medical Info is an app that stores all your relevant health history and insurance details. This makes filling out those endless forms a little less challenging, since you won’t have to rely on your memory for all the details. The app will also allow you to program in doctors’ appointments and all the medications you’re taking. Fooducate helps you keep track of your diet and make healthy choices. Eating well is an integral part of managing any chronic illness and this app will help you to eat the right foods and get you to a healthy body weight. You can program in how many calories you want to consume a day and then add in the food choices you make, the app will work out the nutritional values of everything you eat and tell you how many calories you’ve consumed. It also works in conjunction with many fitness apps to add in details of any physical activities and calories burned. Sleep Cycle helps you get the best out of your sleep. The app analyzes how much sleep and the quality of sleep you get each night and you can also have the alarm set to wake you when you’re in your lightest sleep, leaving you feeling less groggy and more refreshed each day. MORE: Nine tips to help you live better with lupus. Lupus News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. https://lupusnewstoday.com/2017/07/17/6-best-apps-chronic-illness-management/?utm_source=LUP+NEws+E-mail+List --
  17. GSK receives FDA approval for a new self-injectable formulation of Benlysta (belimumab) for systemic lupus erythematosus Issued: London, UK GSK receives FDA approval for a new self-injectable formulation of Benlysta (belimumab) for systemic lupus erythematosus GSK announced today that the US Food and Drug Administration (FDA) has approved a new subcutaneous formulation of Benlysta (belimumab) for the treatment of adult patients with active, autoantibody‑positive SLE who are receiving standard therapy. Systemic Lupus Erythematosus (SLE) is the most common form of lupus, a chronic, incurable autoimmune disease producing autoantibodies that can attack almost any system in the body. The approval marks the first subcutaneous self-injection treatment option for patients with SLE. After training from their health care provider, patients will be able to administer the medicine as a once weekly injection of 200mg, from either a single-dose prefilled syringe or from a single-dose autoinjector. This is the second formulation of Benlysta to be granted approval for SLE, adding to the existing intravenous (IV) formulation, approved in 2011, which is administered by healthcare professionals to patients as a weight-based dose of 10mg/kg, via a one-hour infusion in a hospital or clinic setting every four weeks (following an initial loading phase given on days 0, 14 and 28). Vlad Hogenhuis, Senior Vice President, Head of Specialty Care, GSK said, “We are delighted with today’s decision. Lupus can impact the lives of patients in many different ways with varied and often unpredictable symptoms. Since it launched in its IV form, thousands of patients worldwide have received treatment with Benlysta. The approval of the new injectable formulation will now provide an additional choice for patients, allowing them to self-administer their medicine at home rather than going to hospitals or clinics for their infusions.” The approval is based on data from the BLISS-SC phase III pivotal study of more than 800 patients with active SLE, which measured reduction in disease activity at Week 52 in patients receiving belimumab plus standard of care, versus those receiving placebo plus standard of care (assessed by SRI, a composite measure of efficacy in lupus). Benlysta subcutaneous formulation will be available in specialty pharmacies in the US in late August. Further regulatory submissions for the subcutaneous formulation of Benlysta are under review or planned in other countries during the course of 2017. About Benlysta (belimumab) Benlysta is currently the only medicine specifically developed and approved for SLE. Benlysta, a BLyS-specific inhibitor, is a human monoclonal antibody that binds to soluble BLyS. Benlysta does not bind B cells directly. By binding BLyS, Benlysta inhibits the survival of B cells, including autoreactive B cells, and reduces the differentiation of B cells into immunoglobulin-producing plasma cells. Benlysta is indicated in the US for the treatment of adult patients with active, autoantibody‑positive, systemic lupus erythematosus (SLE) who are receiving standard therapy: Limitations of Use: The efficacy of Benlysta has not been evaluated in patients with severe active lupus nephritis or severe active central nervous system lupus. Benlysta has not been studied in combination with other biologics or intravenous cyclophosphamide. Use of Benlysta is not recommended in these situations. Full US prescribing information including Medication Guide will be available in the near future at: gsksource.com. In the meantime, you may request a copy through GSK Communications. Benlysta is licensed in the European Union as an add-on therapy in adult patients with active autoantibody-positive SLE, with a high degree of disease activity (e.g. positive anti-dsDNA and low complement), despite standard therapy. Benlysta subcutaneous formulation is currently not approved in the European Union. For the EU Summary of Product Characteristics for Benlysta, please visit www.ema.europa.eu About systemic lupus erythematosus (SLE) Systemic lupus erythematosus (SLE) is the most common form of lupus, affecting approximately 70 percent of an estimated 5 million people with lupus worldwide. Approximately 170,000-200,000 Americans live with SLE. It is a chronic, incurable autoimmune disease producing autoantibodies that can attack almost any system in the body. Important Safety Information for belimumab Please consult the full Prescribing Information for all the labelled safety information for Benlysta (belimumab). BENLYSTA (belimumab): CONTRAINDICATION BENLYSTA is contraindicated in patients who have had anaphylaxis with belimumab. WARNINGS AND PRECAUTIONS MORTALITY There were more deaths reported with BENLYSTA than with placebo during the controlled period of the intravenous clinical trials. Out of 2,133 patients in 3 clinical trials, a total of 14 deaths occurred during the placebo-controlled, double-blind treatment periods: 3/675 (0.4%), 5/673 (0.7%), 0/111 (0%), and 6/674 (0.9%) deaths in the groups receiving placebo, BENLYSTA 1 mg/kg, BENLYSTA 4 mg/kg, and BENLYSTA 10 mg/kg, respectively. Etiologies included infection, cardiovascular disease, and suicide. In the controlled clinical trial of BENLYSTA administered subcutaneously (N = 836), a total of 5 deaths occurred during the placebo-controlled, double-blind treatment period (0.7% [2/280] of patients receiving placebo and 0.5% [3/556] of patients receiving BENLYSTA). Infection was the most common cause of death. SERIOUS INFECTIONS Serious and sometimes fatal infections have been reported in patients receiving immunosuppressive agents, including BENLYSTA. Caution should be exercised when considering use in patients with severe or chronic infections. Consider interrupting therapy with BENLYSTA in patients who develop a new infection while receiving BENLYSTA and monitor these patients closely. In controlled clinical trials of BENLYSTA administered intravenously, serious infections occurred in 6.0% and 5.2% of patients receiving BENLYSTA and placebo, respectively. The most frequent serious infections included pneumonia, urinary tract infection, cellulitis, and bronchitis. Infections leading to discontinuation of treatment occurred in 0.7% and 1.0% of patients receiving BENLYSTA and placebo, respectively. Infections resulting in death occurred in 0.3% (4/1,458) and 0.1% (1/675) of patients receiving BENLYSTA and placebo, respectively. In the controlled trials of BENLYSTA administered subcutaneously (N = 836), serious infections occurred in 4.1% and 5.4% of patients receiving BENLYSTA and placebo, respectively. Progressive Multifocal Leukoencephalopathy (PML): Cases of JC virus-associated PML resulting in neurological deficits, including fatal cases, have been reported in patients with SLE receiving immunosuppressants, including BENLYSTA. Risk factors for PML include treatment with immunosuppressant therapies and impairment of immune function. Consider the diagnosis of PML in any patient presenting with new-onset or deteriorating neurological signs and symptoms and consult with a neurologist or other appropriate specialist as clinically indicated. In patients with confirmed PML, consider stopping immunosuppressant therapy, including BENLYSTA. HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS) Acute hypersensitivity reactions, including anaphylaxis and death, have been reported in association with BENLYSTA. These events generally occurred within hours of the infusion; however, they may occur later. Non-acute hypersensitivity reactions including rash, nausea, fatigue, myalgia, headache, and facial edema have been reported and typically occurred up to a week following the most recent infusion. Hypersensitivity, including serious reactions, has occurred in patients who have previously tolerated infusions of BENLYSTA. Limited data suggest that patients with a history of multiple drug allergies or significant hypersensitivity may be at increased risk. In the controlled clinical trials of BENLYSTA administered intravenously, hypersensitivity reactions occurring on the day of the infusion were reported in 13% (191/1,458) and 11% (76/675) of patients receiving BENLYSTA and placebo, respectively. Anaphylaxis was observed in 0.6% (9/1,458) and 0.4% (3/675) of patients receiving BENLYSTA and placebo, respectively. Manifestations included hypotension, angioedema, urticaria or other rash, pruritus, and dyspnea. Some patients (13%) received premedication, which may have mitigated or masked a hypersensitivity response. There is insufficient evidence to determine whether premedication diminishes the frequency or severity of these reactions. Healthcare providers should be aware of the risk of hypersensitivity reactions and be prepared to manage anaphylaxis. In the event of a serious hypersensitivity reaction, discontinue BENLYSTA immediately and administer appropriate medical therapy. Patients should be monitored during and for an appropriate period of time after the intravenous administration of BENLYSTA. Patients receiving BENLYSTA should be informed of the signs and symptoms of an acute hypersensitivity reaction, and be instructed to seek immediate medical care should a reaction occur. In the controlled trial of BENLYSTA administered subcutaneously (N = 836), the incidence and severity of systemic hypersensitivity reactions were similar to those observed in the intravenous clinical trials. INFUSION REACTIONS In the controlled clinical trials, infusion reactions occurring on the day of the infusion were reported in 17% (251/1,458) and 15% (99/675) of patients receiving BENLYSTA and placebo, respectively. Serious infusion reactions (excluding hypersensitivity reactions) were reported in 0.5% and 0.4% of patients receiving BENLYSTA and placebo, respectively. Serious infusion reactions included bradycardia, myalgia, headache, rash, urticaria, and hypotension. The most common infusion reactions occurring in ≥3% of patients receiving BENLYSTA were headache, nausea, and skin reactions. Some patients (13%) received premedication, which may have mitigated or masked an infusion reaction; however, there is insufficient evidence to determine whether premedication diminishes the frequency or severity of these reactions. BENLYSTA should be administered by healthcare providers prepared to manage infusion reactions. The infusion rate may be slowed or interrupted if the patient develops an infusion reaction. Healthcare providers should be aware of the risk of hypersensitivity reactions, which may present as infusion reactions, and monitor patients closely. DEPRESSION In controlled clinical trials of BENLYSTA administered intravenously, serious psychiatric events were reported in 0.8% and 0.4% of patients receiving BENLYSTA and placebo, respectively. Serious depression was reported in 0.4% and 0.1% of patients receiving BENLYSTA and placebo, respectively. Two suicides were reported in patients receiving BENLYSTA. In the controlled trial of BENLYSTA administered subcutaneously, serious psychiatric events were reported in 0.2% of patients receiving BENLYSTA and in no patients receiving placebo. It is unknown if treatment with BENLYSTA is associated with increased risk for these events. Instruct patients to contact their healthcare provider if they experience new or worsening depression, suicidal thoughts, or other mood changes. MALIGNANCY The impact of treatment with BENLYSTA on the development of malignancies is not known. The mechanism of action of BENLYSTA could increase the risk for the development of malignancies. IMMUNIZATION Live vaccines should not be given for 30 days before or concurrently with BENLYSTA. BENLYSTA may interfere with the response to immunizations. USE WITH BIOLOGIC THERAPIES OR IV CYCLOPHOSPHAMIDE BENLYSTA has not been studied in combination with other biologic therapies, including B-cell targeted therapies, or IV cyclophosphamide. Therefore, use of BENLYSTA is not recommended in combination with these therapies. ADVERSE REACTIONS Intravenous administration Adverse reactions, regardless of causality, occurring in at least 3% of patients with SLE who received BENLYSTA 10 mg/kg and placebo respectively and, at an incidence at least 1% greater than that observed with placebo in the 3 controlled studies, were: nausea 15% and 12%; diarrhea 12% and 9%; pyrexia 10% and 8%; nasopharyngitis 9% and 7%; bronchitis 9% and 5%; insomnia 7% and 5%; pain in extremity 6% and 4%; depression 5% and 4%; migraine 5% and 4%; pharyngitis 5% and 3%; cystitis 4% and 3%; leukopenia 4% and 2%; viral gastroenteritis 3% and 1%. Subcutaneous administration The safety profile observed for BENLYSTA administered subcutaneously was consistent with the known safety profile of BENLYSTA administered intravenously, with the exception of local injection site reactions, which occurred in 6.1% and 2.5% of patients receiving BENLYSTA and placebo, respectively. OTHER IMPORTANT INFORMATION FOR BENLYSTA USE IN SPECIFIC POPULATIONS Pregnancy: There are insufficient data on use of BENLYSTA in pregnant women to establish whether there is drug-associated risk for major birth defects or miscarriage. Following an assessment of benefit versus risk, if prevention is warranted, women of childbearing potential should use effective contraception during treatment and for at least 4 months after the final treatment. Lactation: There is no information available on the presence of belimumab in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for BENLYSTA and any potential adverse effects on the breastfed child from BENLYSTA or from the underlying maternal condition. Black/African American Patients: In controlled clinical trials of BENLYSTA administered intravenously, SLE Responder Index-4 (SRI-4) response rates were lower for black/African American patients receiving BENLYSTA relative to black/African American patients receiving placebo. In the controlled trial of BENLYSTA administered subcutaneously, SRI-4 response was slightly higher for black/African American patients receiving BENLYSTA relative to black/African American patients receiving placebo, but the treatment difference was not as great as that observed in the overall population. Use with caution in black/African American patients. Populations not studied Benlysta has not been studied in the following patient groups, and is not recommended in patients with: ∙ severe active central nervous system lupus ∙ severe active lupus nephritis ∙ HIV ∙ a history of, or current, hepatitis B or C ∙ hypogammaglobulinaemia (IgG <400 mg/dl) or IgA deficiency (IgA <10 mg/dl) ∙ a history of major organ transplant or hematopoietic stem /cell /marrow transplant or renal transplant.
  18. Researchers identify new genetic markers in patients with lupus Langefeld CD, et al. Nat Commun. 2017;doi:10.1038/ncomms16021. July 21, 2017 Among patients with lupus, researchers have identified new genetic markers that predispose patients to the disease, according to a recently published study. “This study is the largest multi-ethnic lupus genetics study to date and allowed us to identify many new genetic markers, some of which are specific to individual ethnic groups and others that are shared across ethnicities,” Carl Langefeld, PhD, lead author of the study and professor of biostatistical sciences at Wake Forest School of Medicine, said in a press release. “With this information, we can begin to better understand the differences in the rates and severity of disease across ethnic groups.” Researchers assessed 27,574 participants. They identified 58 distinct non-human leukocyte antigen regions in the Europeans, nine in the Africans and 16 in the Hispanic Americans. All of these included 24 new lupus regions. “In addition, we observed that many of the genetic markers associated with lupus are shared across numerous autoimmune diseases, and those that are not shared may allow us to understand why a person develops lupus instead of another autoimmune disease,” Langefeld said. “These results will help us identify the biological pathways that pharmaceutical companies may target, and ultimately, develop personalized medicine for the treatment of lupus.” Reference: www.wakehealth.edu/News-Releases/2017/Large_Multiethnic_Study_Identifies_Many_New_Genetic_Markers_for_Lupus.htm Large Multi-ethnic Study Identifies Many New Genetic Markers for Lupus WINSTON-SALEM, N.C. – July 17, 2017 – Scientists from an international consortium have identified a large number of new genetic markers that predispose individuals to lupus. The study is published in the July 17 issue of the journal Nature Communications and was led by researchers at Wake Forest Baptist Medical Center, Oklahoma Medical Research Foundation, King’s College of London and Genentech Inc. Autoimmune diseases strike one in 15 Americans, are among the top 10 causes of death in women and cost an estimated $100 billion a year in medical care. In autoimmune diseases, the body attacks itself. Systemic lupus erythematosus, the form of lupus studied here, is the most common type of lupus and is a prototypical autoimmune disease. Lupus strikes women nine times more often than men and its onset is most common during childbearing age. Also, African-American and Hispanic women are two to three times more likely to develop lupus and tend to have more severe cases than Caucasian women. At present, there is no cure for lupus, which can affect many parts of the body, including joints, skin, kidney, heart, lungs, blood vessels and brain, according to the Lupus Research Alliance. “This study is the largest multi-ethnic lupus genetics study to date and allowed us to identify many new genetic markers, some of which are specific to individual ethnic groups and others that are shared across ethnicities,” said Carl Langefeld, Ph.D., lead author of the study and professor of biostatistical sciences at Wake Forest School of Medicine, a part of Wake Forest Baptist. “With this information, we can begin to better understand the differences in the rates and severity of disease across ethnic groups. “In addition, we observed that many of the genetic markers associated with lupus are shared across numerous autoimmune diseases, and those that are not shared may allow us to understand why a person develops lupus instead of another autoimmune disease. These results will help us identify the biological pathways that pharmaceutical companies may target, and ultimately, develop personalized medicine for the treatment of lupus.” This study analyzed genetic data from 27,574 individuals of European, African American and Hispanic ancestry using the Immunochip, a genotyping technology designed specifically for autoimmune diseases. The researchers identified 58 regions of the genome in Caucasians, nine in African Americans and 16 in Hispanics. These regions appear independent of the well-known Human Leukocyte Antigen (HLA) associations, also studied in depth here. An important observation was that nearly 50 percent of these regions had multiple genetic variants that predispose someone to lupus, Langefeld said. Another key finding was that as the number of genetic risk variants (alleles) a person has increases, the risk for lupus increases more than expected if the variants were working independently. These observations led the authors to propose a “cumulative hits hypothesis for autoimmune disease”. In future research, the team hopes to better understand how these genetic variants influence the risk of lupus, identify any possible drug targets and determine if any environmental factors, such as infections, can trigger the development of the disease in someone who has a genetic susceptibility. They emphasize that it is important to increase the number of understudied populations, such as African-American and Hispanic, to better understand the genetic causes of health disparities in lupus and the unique risks in all ethnic groups. “We are delighted to see the work we funded on the ImmunoChip come to fruition and congratulate Dr. Langefeld along with his colleagues on this tremendous success," said Kenneth M. Farber, CEO and President, Lupus Research Alliance. "This study is among the few to concentrate heavily on non-Caucasian populations for a significantly broader evaluation, while utilizing the most current and comprehensive information about human DNA.” Key support for the study was provided by the Lupus Research Alliance and the National Institutes of Health. Additional corresponding authors are: Patrick M. Gaffney, M.D., Oklahoma Medical Research Foundation; Robert R. Graham, Ph.D., Genentech, Inc.; and Timothy J. Vyse, M.D., Ph.D., King’s College London. Media Relations Contacts: Marguerite Beck: marbeck@wakehealth.edu,336-716-2415
  19. Large Multi-ethnic Study Identifies Many New Genetic Markers for Lupus http://www.wakehealth.edu/News-Releases/2017/Large_Multiethnic_Study_Identifies_Many_New_Genetic_Markers_for_Lupus.htm WINSTON-SALEM, N.C. – July 17, 2017 – Scientists from an international consortium have identified a large number of new genetic markers that predispose individuals to lupus. The study is published in the July 17 issue of the journal Nature Communications and was led by researchers at Wake Forest Baptist Medical Center, Oklahoma Medical Research Foundation, King’s College of London and Genentech Inc. Autoimmune diseases strike one in 15 Americans, are among the top 10 causes of death in women and cost an estimated $100 billion a year in medical care. In autoimmune diseases, the body attacks itself. Systemic lupus erythematosus, the form of lupus studied here, is the most common type of lupus and is a prototypical autoimmune disease. Lupus strikes women nine times more often than men and its onset is most common during childbearing age. Also, African-American and Hispanic women are two to three times more likely to develop lupus and tend to have more severe cases than Caucasian women. At present, there is no cure for lupus, which can affect many parts of the body, including joints, skin, kidney, heart, lungs, blood vessels and brain, according to the Lupus Research Alliance. “This study is the largest multi-ethnic lupus genetics study to date and allowed us to identify many new genetic markers, some of which are specific to individual ethnic groups and others that are shared across ethnicities,” said Carl Langefeld, Ph.D., lead author of the study and professor of biostatistical sciences at Wake Forest School of Medicine, a part of Wake Forest Baptist. “With this information, we can begin to better understand the differences in the rates and severity of disease across ethnic groups. “In addition, we observed that many of the genetic markers associated with lupus are shared across numerous autoimmune diseases, and those that are not shared may allow us to understand why a person develops lupus instead of another autoimmune disease. These results will help us identify the biological pathways that pharmaceutical companies may target, and ultimately, develop personalized medicine for the treatment of lupus.” This study analyzed genetic data from 27,574 individuals of European, African American and Hispanic ancestry using the Immunochip, a genotyping technology designed specifically for autoimmune diseases. The researchers identified 58 regions of the genome in Caucasians, nine in African Americans and 16 in Hispanics. These regions appear independent of the well-known Human Leukocyte Antigen (HLA) associations, also studied in depth here. An important observation was that nearly 50 percent of these regions had multiple genetic variants that predispose someone to lupus, Langefeld said. Another key finding was that as the number of genetic risk variants (alleles) a person has increases, the risk for lupus increases more than expected if the variants were working independently. These observations led the authors to propose a “cumulative hits hypothesis for autoimmune disease”. In future research, the team hopes to better understand how these genetic variants influence the risk of lupus, identify any possible drug targets and determine if any environmental factors, such as infections, can trigger the development of the disease in someone who has a genetic susceptibility. They emphasize that it is important to increase the number of understudied populations, such as African-American and Hispanic, to better understand the genetic causes of health disparities in lupus and the unique risks in all ethnic groups. “We are delighted to see the work we funded on the ImmunoChip come to fruition and congratulate Dr. Langefeld along with his colleagues on this tremendous success," said Kenneth M. Farber, CEO and President, Lupus Research Alliance. "This study is among the few to concentrate heavily on non-Caucasian populations for a significantly broader evaluation, while utilizing the most current and comprehensive information about human DNA.” Key support for the study was provided by the Lupus Research Alliance and the National Institutes of Health. Additional corresponding authors are: Patrick M. Gaffney, M.D., Oklahoma Medical Research Foundation; Robert R. Graham, Ph.D., Genentech, Inc.; and Timothy J. Vyse, M.D., Ph.D., King’s College London. Media Relations Contacts: Marguerite Beck: marbeck@wakehealth.edu,336-716-2415
  20. Speakers: Lupus remains challenging disease July 6, 2017 Healio Rheumatology recently interviewed Richard Furie, MD, from Hofstra Northwell School of Medicine, Lars Rönnblom, MD, from Uppsala University in Sweden, and Peggy K. Crow, MD, from Hospital for Special Surgery, about the future of lupus during the Interferon Summit. “We need better drugs,” Furie said. “There is a major need for safer and more efficacious therapies. The typical patient who gets this disease is a young woman and it can be devastating.” SEE ALSO Furie discusses advances in SLE treatment Through the Cracks: Niche Patient Population Battles... Elusive Target: A Rundown of the Drug Pipeline for Systemic... Richard Furie To illustrate the need for better therapies, Furie discussed the progression of treatments for the disease. “We have come a long way with treatments,” he said. “If you go back before steroids were developed, the mortality was high. It was probably 50% at 7 years, but steroids were introduced and they have been a major advance. Then, after that, it was the immunosuppressives; but, until we get rid of all mortality and morbidity, we need new drugs.” To derive better therapies for a disease, there needs to be better disease classification. Rönnblom talked about the current classification of lupus patients and how to treat the underlying cause vs. a cluster of symptoms. “We classify patients with an auto[body] or antibody profile,” Rönnblom said. “In lupus, we classify them according to organ manifestation, but also when they have this interferon signature. My guess is that we will see more pathways coming up. Much of this data will be generated by the clinical trials, of course, who responds and who does not respond.” Lars Rönnblom Crow said better understanding about the molecular pathway and underlying mechanisms of the disease can lead to better therapy. “My own speculation is that we will probably end up with combination therapies and maybe combinations will allow us to use lower doses, each of one or two or three therapies to avoid toxicity. For example, we might want to target this type 1 interferon pathway that I believe is active in a sustained way throughout the disease, but may be more important in some stages than others,” she said. Peggy K. Crow “To have a more effective therapeutic activity, we might also want to target activated T cells or B cell differentiation. My guess is that we, as a community, will end up trying different combinations and some of the selection of those might be informed by the molecular pathways that an individual shows to be activated or abnormal.” – by Will A. Offit Disclosures: The researchers report no relevant financial disclosures. https://www.healio.com/rheumatology/lupus/news/online/{0b28f725-2f50-4168-b619-abd1de8a4266}/speakers-lupus-remains-challenging-disease?utm_source=selligent&utm_medium=email&utm_campaign=rheumatology news&m_bt=1879111151405
  21. Glucocorticoids Use and Organ Damage in Lupus http://www.rheumatologynetwork.com/lupus/glucocorticoids-use-and-organ-damage-lupus Glucocorticoids exposure is strongly associated with the accrual of irreversible organ damage in systemic lupus erythematosus patients, independent of disease activity, researchers report. “Our findings suggest that only extremely low doses of glucocorticoid can be considered free of association with damage accrual in patients with SLE,” write researchers in the Nov. 22 issue of Lupus Science and Medicine Glucocorticoids are a mainstay treatment in both acute and chronic systemic lupus erythematosus. Previous studies have demonstrated that damage accrual is associated with cumulative disease activity. However, more recent studies suggest that damage accrual may also be associated with systemic lupus erythematosus treatment. Approximately 60 percent of systemic lupus erythematosus patients experience permanent organ damage within seven years of being diagnosed with the disease. Given that glucocorticoids are often used in the context of high disease activity, it has been challenging for researchers to tease out the independent effect of systemic lupus erythematosus treatment on damage accrual. This was an observational study of 162 systemic lupus erythematosus patients — 75 percent of whom received glucocorticoids. The patients were observed for two to 4.7 years by Diane Apostolopoulos, M.D., of Monash University in Australia, and colleagues. They measured damage accrual finding that glucocorticoid patients were 42 percent more likely to have significantly more damage as compared to patients who were not prescribed glucocorticoids (42% vs 15%, p<0.01). The observational nature of the study was one of the limitations of the study, yet, it is noteworthy, the researchers wrote. “Given the limitations of observational studies in the face of confounding by indication, our findings suggest the urgent need for a randomized study comparing the effect on damage accrual of usual care with that of a strategy that stringently limits glucocorticoid dosing,” Dr. Apostolopoulos and colleagues wrote. In an editorial that was published online April 7 in Lupus Science and Medicine, Maarten Boers, M.D., of VU University Medical Center in the Netherlands, conveys concerns of the medical community misinterpreting observational studies by limiting applications of a potentially life-saving treatment. “The truth of the matter is that trials on glucocorticoid beneficial and adverse effects are not being done, and that observational studies (invariably only focusing on glucocorticoid adverse effects, both related and unrelated to the disease) are hopelessly and irretrievably confounded by indication,” wrote Boers. “In brief, patients with the most severe disease are preferentially treated with glucocorticoids, and this leads to the associations found in observational studies, regardless of the beneficial effects of glucocorticoids.” The study Glucocorticoid use is associated with harm in both domains of the (Systemic Lupus International Collaborating Clinics Damage Index (SDI) traditionally associated with glucocorticoid-induced harm (cataracts, osteoporotic fracture, avascular necrosis, diabetes mellitus) and the residual SDI domains not previously associated with glucocorticoid-induced harm. Even lower doses of glucocorticoid are associated with damage accrual in SLE. The threshold identified was a time-adjusted mean prednisolone of 4.4 mg per day. Cumulative prednisolone exposure was associated with overall damage accrual after controlling for ethnicity and disease activity and was significant at time-adjusted mean doses above 4.42 mg prednisolone per day. A dose-response relationship between cumulative prednisolone use and irreversible organ damage accrual was observed, with increasing odds ratios with each ascending quartile. Compared to patients in the lowest quartile, patients in the highest quartile of cumulative prednisolone had adjusted odds ratio of 13.46, 95 percent CI (3.59 to 50.4), p<0.01 for damage accrual. Of the demographic factors evaluated, only ethnicity was associated with damage accrual. Asian patients had reduced odds of damage accrual compared with Caucasians (adjusted OR=0.22, 95% CI (0.09 to 0.53), p<0.01). “Our findings further emphasize the need for new, more effective treatments for SLE that minimize or eliminate the need for glucocorticoids,” wrote Apostolopoulos and team. DISCLOSURES This research was supported by a grant from Eli Lilly. REFERENCES Apostolopoulos D, Kandane-Rathnayake R, Raghunath S, et al. “Independent association of glucocorticoids with damage accrual in SLE,” Lupus Science and Medicine. Published online November 22, 2016. DOI: 10.1136/lupus-2016-000157. Boers M. “Observational studies on glucocorticoids are harmful!” Lupus Science and Medicine. Published online April 7, 2017. DOI: 10.1136/lupus-2017-000219
  22. Women with Lupus Overwhelmingly Have Healthy Pregnancies News | June 30, 2017 | Lupus By Whitney L. Jackson In contradiction to long-standing beliefs, a healthy pregnancy is possible for women who have lupus, says Jill Buyon, M.D., a rheumatologist and lupus specialist from New York University School of Medicine. “Patients with lupus have been under the impression that pregnancy would be a very dangerous thing for them. From the mother’s perspective, the concerns are: Will the mother sustain a lupus flare? For mothers who have once had kidney involvement: How safe is it to get pregnant? Will there be adverse pregnancy outcomes? Will the baby be very small? Will the baby be born so early that it needs to be in the hospital for a long time. And, of course, the scary question is: Will my baby die? These are the outcomes we look at from the perspective of counseling and what we wanted to learn from this study,” she said. Dr. Buyon recently published research in the Annals of Internal Medicine showing that women with relatively inactive lupus without serious flares experienced a normal pregnancy with a positive outcome. Study participants were women, ages 18-to-45, enrolled in the Predictors of Pregnancy Outcome: Biomarker in Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus (PROMISSE) Trial. The investigation was multi-center, multi-racial and multi-ethnic. Out of the 385 women followed during the study, 81 percent experienced no adverse events. Overall, 9 percent of pregnancies resulted in premature birth, 4 percent experienced pregnancy loss during the second or third trimester, 1 percent encountered infant death due to pregnancy complications, and 10 percent had very low birth weight. Throughout the study, investigators identified four factors that appeared to increase a woman's likelihood for a negative outcome — high blood pressure during pregnancy, more active lupus during gestation, low platelet count, and a positive lupus anticoagulant test during the first trimester. “The patients who tended to be more sick at the outset, tended to be those who might have an adverse pregnancy outcome. The highest risk factor is the presence of something called a lupus anticoagulant. The presence of this abnormal blood test is very important and one that absolutely all doctors should test for,” Dr. Buyon said. In addition, race and ethnicity — black, Hispanic and Asian — contributed to poor outcomes and was in and of itself, a risk factor. Dr. Buyon said she doubts it is due to socioeconomic factors because the patients were treated by similar doctors in tertiary care centers. She suspects it may be due to genetics, which needs to be explored. Although the findings point to the possibility of healthy pregnancies for this population, Dr. Buyon cautioned women who have high protein levels in urine due to uncontrolled kidney disease could still face significant problems with pregnancy. These women are typically advised to postpone pregnancy until their kidney disease improves. Ten to 15 percent of patients had a moderate flare requiring minimal medication changes, but less than 5 percent of patients had a flare that required high dose steroids or hospitalization. About one in five patients had a renal flare. “The other optimistic perspective was that 225 patients never had kidney disease, but many of them had anti DNA antibodies which is an antibody we worry about in developing renal disease. Only four people developed de novo renal disease. For people who had previous kidney disease ... but were in complete remission, they too had very few renal flares. I think this is very encouraging news for women with past renal disease who really are so worried that maybe they’ll never have a healthy pregnancy, that simply is not true (14:01),” Dr. Buyon said. The hope, she said, is that these findings can be used to inform discussions between doctors and their patients with lupus who are also interested in pursuing pregnancy. Dr. Buyon discusses the study, its findings and implications in the following video with Rheumatology Network. http://www.rheumatologynetwork.com/lupus/women-lupus-overwhelmingly-have-healthy-pregnancies REFERENCES Jill P. Buyon, MD; Mimi Y. Kim, ScD; Marta M. Guerra, MS, et al. "Predictors of Pregnancy Outcomes in Patients With Lupus: A Cohort Study," Annals of Internal Medicine, Aug. 4, 2015. DOI: 10.7326/M14-2235
  23. Systemic lupus erythematosus increases risk for cervical neoplasia June 15, 2016 LONDON — Women with systemic lupus erythematosus, or SLE, are at a greater risk for cervical neoplasia, especially those treated with immunosuppressive drugs, according to a speaker here at the EULAR Annual Congress. “Women with SLE appear to be at increased risk for cervical neoplasia. It is more pronounced for premalignant and invasive cancers,” Johan Askling, MD, PhD,from the department of medicine at Karolinska Institutet in Stockholm, Sweden, said during a press conference. “Treatment with SLE is a marker of further increasing the risk. In fact, it contains the overall increase for invasive cancers, but whether this is due to drugs or the indication, we do not really know.” Askling and colleagues identified 4,450 women with SLE from Swedish registries and 28,113 matched controls from the general population. The Swedish National Cervical Screening Registry was used to collect data on cervical screenings. Patients were further divided by whether they used antimalarial drugs (n = 1,783) or other immunosuppressive treatments (n = 1,981), as defined by the Swedish Prescribed Drug Register. At follow-up, the Swedish National Cervical Screening Registry and Swedish Cancer Registry were used to determine outcomes of cervical dysplasia and invasive cervical cancer. Other outcomes assessed separately included cervical intraepithelial neoplasia grades 1 and 2/3, and invasive malignancy. Askling and colleagues used Cox models to estimate hazard ratios. Investigators found women with SLE had a doubled rate for cervical dysplasia or invasive cancer compared with the general population. Women treated with systemic immunosuppressive drugs vs. those treated with antimalarial drugs had a higher rate for cancer. Immunosuppressives were correlated with a higher chance of cervical dysplasia or neoplasms compared with women treated with antimalarials. “Women with SLE should be screened for cervical cancer, and if there is a population-based screening program … [it] is particularly good to adhere to that program,” Askling said. “We do not think, at this stage, additional measures should be taken.” – by Monica Jaramillo Reference: Wadström H, et al. Abstract #OP0189. Presented at: EULAR Annual Congress; June 8-11, 2016; London. Disclosure: Askling reports no relevant financial disclosures.
  24. EULAR publishes recommendations for women with lupus Andreoli L, et al. Ann Rheum Dis. 2017;doi:10.1136/annrheumdis-2016-209770. March 9, 2017 A team of EULAR researchers published recommendations for health issues and family planning for women with lupus or antiphospholipid syndrome. Laura Andreoli, PhD, in the Department of Clinical and Experimental Sciences at the University of Brescia in Italy, and colleagues performed a systematic review of evidence and compiled questions and expert opinions to reach a consensus. According to a published extended report, they made the following recommendations for women with lupus or antiphospholipid syndrome: family planning should be discussed after disease diagnosis; most women can have successful pregnancies, and steps can be taken to reduce adverse maternal or fetal outcomes; risk stratification includes disease activity, autoantibody profile, previous vascular morbidity, previous pregnancy morbidity, hypertension and drug use — with an emphasis on the use of hydroxychloroquine and anti-platelets or anti-coagulants; for patients with stable and inactive disease and a low risk for thrombosis, hormonal contraception and menopause replacement therapy can be used; fertility preservation with gonadotropin-releasing hormone analogues should be considered before use of alkylating agents; assisted reproduction techniques are safe for patients with stable and inactive disease; anticoagulants or low-dose aspirin should be given to patients with positive antiphospholipid antibodies; assessment of disease activity, renal function and serological markers is important to diagnose disease flares and monitor adverse obstetrical results; fetal monitoring includes Doppler ultrasonography and fetal biometry — especially in the third trimester — to screen for placental insufficiency and fetuses that are small given gestational age; gynecological malignancy screens are similar to that of the general population, but with increased vigilance for cervical premalignant lesions if patients exposed to immunosuppressive drugs; and the human papillomavirus vaccine can be given in women with stable and inactive disease. – by Will Offit Disclosure : The researchers report no relevant financial disclosures. Perspective This helpful review from EULAR represents a paradigm shift in the management of reproductive health in patients with systemic lupus erythematosus (SLE). We as physicians can ensure patients with SLE achieve healthy pregnancies starting with knowledge of contraception to prevent unwanted pregnancies, and appropriate prenatal risk stratification. With wider availability of varied contraception methods, we can offer IUDs, particularly non-hormonal copper, to all SLE patients of reproductive age. While hormonal contraception methods, such as oral contraceptive pills and patches, have been shown to be safe and effective in patients with stable disease and no APL antibodies, these methods should be used with caution in patients with increased thrombotic risk. In women who wish to become pregnant, fertility counseling should be offered with special attention to treatments which may limit fertility, including alkylating agents, and need to delay pregnancy due to disease activity. If alkylating agents cannot be avoided, preservation of fertility techniques, such as administration of gonadotropin-releasing hormone analogues can be considered. Importantly, SLE patients without risk factors such as active disease (including nephritis), antiphospholipid antibody syndrome, and Ro antibodies most often have healthy pregnancies. Strategies to prevent pregnancy complications include ensuring 6 disease-inactive prenatal months, continuing hydroxychloroquine during pregnancy, and low dose aspirin particularly in antiphospholipid antibody (APL) positive patients. Perinatal SLE may be managed using low-dose oral glucocorticoids, azathioprine or calcineurin inhibitors. APL-positive patients should get ultrasounds and biometric parameters, particularly during the third trimester to screen for placental insufficiency and small for gestational age fetuses. Ro-positive patients should be screened for fetal congenital heart block in the second trimester. Emerging evidence suggests hydroxychloroquine may significantly reduce CHB risk particularly in Ro-positive mothers with prior affected pregnancies. Finally, apart from cervical dysplasia due to human papillomavirus (HPV), gynecological malignancies do not have increased prevalence in SLE, therefore screening should follow age appropriate protocols. All young women with SLE should be offered HPV vaccination. Ashira D. Blazer, MD Instructor of Medicine Division of Rheumatology NYU Langone Medical Center New York Disclosures: Blazer reports no relevant financial disclosures.
  25. Longterm hydroxychloroquine therapy may reduce cardiovascular events in SLE June 16, 2017 MADRID — Long-term use of hydroxychloroquine was associated with reduced cardiovascular risks in a cohort of patients with systemic lupus erythematosus,according to findings presented at the EULAR Annual Congress. “[Systemic lupus erythematosus] SLE may be considered a coronary heart disease condition,” Serena Fasano, MD, of the Rheumatology Unit at the University of Campania Luigi Vanvitelli in Naples, said. “Patients should be investigated for traditional and SLE-related risk factors. SLE patients are candidates for aspirin prophylaxis and long-term hydroxychloroquine. Statins are recommended for patients with persistently high LDL cholesterol levels.” The aim of the study was to assess the role of aspirin, hydroxychloroquine and statins as primary prophylaxis of cardiovascular events in SLE. The study included clinical chart reviews of 291 patients with 8 years of follow-up. “The primary outcome was the first cardiovascular event,” Fasano said. Results showed 16 events in that time. There were seven myocardial infarctions and two strokes in the group. The event-free rate was higher in the 120 patients treated with low-dose aspirin (hazard ratio = 0.27) and hydroxychloroquine for more than 5 years (HR = 0.26) than in 98 patients who were treated with aspirin alone or hydroxychloroquine for fewer than 5 years. “Low-dose aspirin and hydroxychloroquine were negative predictors of events,” Fasano said. No such association was reported for statins. Smoking, obesity, hypertriglyceridemia, diabetes mellitus, disease activity, severe SLE, or use of immunosuppressive agents or steroids failed to demonstrate any kind of association with cardiovascular events, according to Fasano. Multivariable analysis results showed the associations between low-dose aspirin (HR = 0.24) or hydroxychloroquine use for longer than 5 years (HR = 0.27) and reduced incidence of cardiovascular events persisted. — by Rob Volansky Reference: Fasano S, et al. Abstract #OP0233. Presented at: EULAR Annual Congress; June 14-17, 2017; Madrid. Disclosure: The researchers report no relevant financial disclosures. Measure Measure
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