Background Treat-to-target strategies in systemic lupus erythematosus (SLE) are thought to be the next step in improving outcome for SLE patients. Composing and validating treatment targets are therefore important. Recently, criteria for remission  and for Lupus Low Disease Activity State (LLDAS) have been proposed.
Objectives To identify predictors of organ damage and specifically the relationship between prolonged disease remission or LLDAS and damage accrual in a longitudinal cohort of SLE patients.
Methods Patients from the Amsterdam SLE cohort were prospectively assessed including the occurrence of minor/major flares, and once a year: remission and LLDAS. To determine which variables were predictive of damage accrual (dependent variable), variables with p<0.10 in univariable analysis were entered into the respective multivariate logistic regression model in a backward stepwise elimination manner. Secondly, odds ratios (ORs) for damage accrual during follow-up were calculated for patients with or without prolonged remission during 5 years, and with or without LLDAS in ≥50% of observations.
Results Data from 183 patients (90.2% female, 68.3% Caucasian) with a median follow-up duration of 5.0 years were analyzed. In univariable analysis, patients with damage accrual had higher SDI scores, number of fulfilled ACR criteria, frequency of nephrological manifestations and hypertension at baseline, higher mean SLEDAI-2K, mean daily doses of prednisone, and frequency of ≥1 major flare during follow-up, and lower frequency of remission at all visits and ≥50% of observations in LLDAS. The most important predictors for damage accrual were: occurrence of ≥1 major flare (OR 5.2, 95% CI 1.8 – 14.5, p=0.002), mean daily prednisone dose during follow-up (OR 1.1, 95% CI 1.0 – 1.2, p=0.03 per increase of 1 mg), and nephrological manifestations at baseline (OR 2.2, 95% CI 1.1 – 4.5, p=0.03). Prolonged remission was present in 32.5% (38/117) and LLDAS in ≥50% of observations in 64.5% (118/183) of patients. Both the presence of prolonged remission during 5 years and LLDAS in ≥50% of observations were associated with a reduced risk of damage accrual (OR 0.20, 95% CI 0.07 – 0.53, p=0.001 and OR 0.52, 95% CI 0.28 – 0.99, p=0.046, respectively).
Conclusions In this observational study, we present for the first time longitudinal data regarding disease activity and damage accrual in our cohort. Prolonged remission and LLDAS were associated with an improved outcome, as determined by yearly assessments. Remission and LLDAS are therefore realistic targets as the respective criteria were fulfilled frequently in our cohort. In order to improve the outcome in SLE patients, future studies should investigate whether these targets can be reached actively with therapeutic strategies.
Zen M et al. Prolonged remission in Caucasian patients with SLE: prevalence and outcomes. Ann Rheum Dis 2015;74:2117–22
Franklyn K et al. Definition and initial validation of a Lupus Low Disease Activity State (LLDAS). Ann Rheum Dis 2015;Oct 12
Disclosure of Interest None declared