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Clinical Decision Making: Evaluating Biologics in Lupus Management - Episode 6

Treat to Target In Lupus Management

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Anne E. Winkler, MD, PhD, MACP and Kristi V. Mizelle, MD, MPH, FACR hypothesize about the role and future of a treat to target approach in patients with lupus.

Anne E. Winkler, MD, PhD, MACP: We don’t have a treat to target approach at this point in terms of lupus because this is such a diverse disease in terms of how it presents. Any kind of comments on whether we’re going to get there in terms of treat to target or anything that you can think about in terms of treating patients?

Kristi V. Mizelle, MD, MPH, FACR: Right. The treat to target conversation is a necessary one for lupus. I think this is very early stages of that conversation. The disease where we’ve had the most success with a treat to target strategy has been rheumatoid arthritis. And we can model some of what we do with SLE after how the treat to target model has been used in rheumatoid arthritis. One of the most important things is what’s the goal you have a treat to target strategy and is it lupus, low disease activity state? Is it remission? Is it an SRI4? What should be the target? That conversation is beginning to start to happen. Just like with rheumatoid arthritis, where there are multiple remission measures, low disease, activity, et cetera, that you can look at as outcomes or goals as far as using the treat to target strategy. The conversation is happening. There are ongoing studies looking at each of those 3 different outcomes as a potential sort of target that we want to shoot for. The conversation is happening, it’s definitely a necessary conversation and as we have more and more tools in our armamentarium for treatment for lupus, that it will hopefully become easier to get to the goal of remission. When I was training, remission and lupus is not something that I thought about very often because it just didn’t happen, patients didn’t get there. But even having the conversation about remission is huge forward motion in the field of rheumatology, as well as the dialogue about permanent organ damage. That’s a huge shift in the rheumatology community in the way that we think about things as far as getting patients to the place of remission, even coming up with a definition of what this remission look like in SLE, is also very important. And things are starting to happen now, there’s a clear diagnosis or a clear sort of understanding or consensus on what remission might be in lupus. All those things are starting to happen, we’re at the very beginning of all of that. What I will say as far as treat to target, one treat to target in general, for me, outcome goal, I think should be no steroids, no corticosteroids.

If we said this 20 years ago, people would look at me like I had 2 heads but it should be no corticosteroids. And it’s not just because I trained with Dr Michelle PG that I say that. It’s because studies show that what we do to patients is how they die in lupus. It’s the long term usage of the steroids, that long term helped to contribute to cardiovascular disease, and other manifestations that ultimately lead to mortality in patients with lupus. It used to be that lupus was the cause of mortality for patients. But nowadays, that’s not as often the case, it’s much more rarely the case. And now, the goal I think, should be shifting from what do we do right now, high steroids, it’s OK to leave them on steroids forever to OK, now we’ve got things under better control, let’s get the steroids off so that we can prolong life in this patient population. Even though that’s not necessarily a treat to target, I wanted to get on my soapbox a little bit about steroids being a very important target to get off with patients who do have lupus.

Anne E. Winkler, MD, PhD, MACP: I’m right up there on that soapbox with you.

Transcript Edited for Clarity