“When you look at the models, it's pretty clear that when the prednisone gets above 11 mg daily, there is a huge increase in the hazard ratio for organ damage,” Dr. Petri said. “That is when to start to think about adding other therapies, if you haven't already, to achieve better control of disease activity and to limit the prednisone dose.” It is at this point, she noted, that the expansion of treatment options is needed.
With respect to other steroid-sparing options, however, the “ideal” immunomodulatory therapy in lupus continues to be the antimalarial hydroxychloroquine (Plaquenil), Dr. Petri said. Hydroxychloroquine “has been shown to prevent severe flares in lupus. It also reduces the risk of lupus nephritis, organ damage, cardiovascular risk factors, and thrombosis, and it improves survival.” In reality, she added, “if we could just convince our patients to stay on Plaquenil, I don't think we would need as much immunosuppressive therapy.”
In fact, hydroxychloroquine is undergoing a rebirth of sorts, according to Dr. Furie. “Many people believe that all SLE patients should be on this drug. It's effective and fairly benign, and we are learning that it has pleiotropic effects,” he said, including protection against thrombotic events and a beneficial effect on lipid profiles, which could potentially help reduce SLE patients' high risk of cardiovascular disease.
The recent finding by Spanish investigators that antimalarial drugs are more effective in SLE patients with polymorphisms on the tumor necrosis factor–alpha (TNF-alpha) and interleukin-10 (IL-10) genes associated with unusually high TNF-alpha levels and unusually low IL-10 levels may eventually allow the identification of lupus patients who are the most likely to benefit from antimalarial therapy (J. Rheumatol. 2008;35:1559-66).
Finally, the lupus research community is encouraged by the development of new recommendations for monitoring SLE in clinical practice, which were introduced at the annual European Congress of Rheumatology this year by Dr. Marta Mosca of the University of Pisa (Italy), the lead author of the recommendation paper, which is slated for publication in the Annals of the Rheumatic Diseases later this year. The guidelines are intended to provide a “road map” for clinicians in terms of assessing disease activity, kidney and other organ involvement, comorbidities, and the various cardiovascular, ophthalmologic, neuropsychiatric, and other risks associated with SLE and its treatment.
“The guidelines will be an important tool for helping rheumatologists make clinical management decisions,” Dr. Mosca said. “As new therapies are developed, the guidelines will help ensure the quality control of patient care and will allow us to better standardize the collection and comparison of data in observational studies.”
The SLE Responder Index 'represents a breakthrough' in detecting disease improvement.
Source DR. WALLACE