van Vollenhoven RF, Mosca M, Bertsias G, et al., Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis. (2014) Apr 16. doi: 10.1136/annrheumdis-2013-205139. Open Access
An international task force of multi-speciality experts says the "treat-to-target" approach can be applied just as effectively in systemic lupus erythematosus (SLE) as it has proven in rheumatoid arthritis.
After a review of current evidence, the panel (including rheumatologists, nephrologists, dermatologists, clinical immunologists, specialists in internal medicine, and a patient representative) decided on 11 therapeutic goals for managing SLE.
The panel also developed four overarching principles for patient care, emphasizing shared decision-making and long-term monitoring.
Acknowledging that these goals may have to be adjusted for patient preference and risks, the treat-to-target-in-SLE (T2T/SLE) panel recommended:
1. The main treatment target in SLE should be remission. If treatment outcomes fall short of remission, the goal should be the lowest possible disease activity as measured by a validated lupus activity index and/or by organ-specific markers.
2. Preventing lupus flares (especially severe flares) is a realistic target and should be a therapeutic goal.
3. Stable or persistent serological activity in clinically asymptomatic patients does not justify escalating treatment.
4. Preventing damage should be a major therapeutic goal, since accumulated injury to organs and joints predicts subsequent damage and death in SLE.
5. Management should address factors that negatively affect health-related quality of life (HRQOL), such as fatigue, pain and depression.
6. Early recognition and treatment of renal involvement in lupus patients is strongly recommended.
7. After induction therapy for lupus nephritis (LN), at least 3 years of immunosuppressive maintenance treatment is recommended.
8. In maintenance treatment, use the lowest glucocorticoid dosage to control disease, and if possible, withdraw glucocorticoids completely.
9. Prevention and treatment of thromboses in antiphospholipid syndrome (APS) should be a therapeutic goal, with the same strategies used in primary APS.
10. Seriously consider anti-malarials, especially hydroxychloroquine, regardless of other treatments used.
11. Adjunctive therapies -- including blood pressure medications, cholesterol and blood glucose-lowering drugs, antiplatelet/anticoagulant agents, and drugs to prevent bone loss –- may be needed to control comorbidities.
Noting a lack of high-level evidence to support its recommendations, the panel also unveiled an 11-point research agenda, calling for prospective randomized clinical trials comparing treat-to-target with standard SLE treatment, and better definitions of remission, flares, and minimal disease activity, among other priorities.