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The number of flares patients experience impacts on damage accrual in systemic lupus erythematosus: data from a multiethnic Latin American cohort
  1. Manuel F Ugarte-Gil1,2,
  2. Eduardo Acevedo-Vásquez1,3,
  3. Graciela S Alarcón4,
  4. Cesar A Pastor-Asurza1,3,
  5. José L Alfaro-Lozano1,
  6. Jorge M Cucho-Venegas1,
  7. Maria I Segami3,5,
  8. Daniel Wojdyla6,
  9. Enrique R Soriano7,
  10. Cristina Drenkard8,
  11. João Carlos Brenol9,
  12. Ana Carolina de Oliveira e Silva Montandon10,
  13. Lilian T Lavras Costallat11,
  14. Loreto Massardo12,
  15. José F Molina-Restrepo13,
  16. Marlene Guibert-Toledano14,
  17. Luis H Silveira15,
  18. Mary Carmen Amigo16,
  19. Leonor A Barile-Fabris17,
  20. Rosa Chacón-Díaz18,
  21. Maria H Esteva-Spinetti19,
  22. Guillermo J Pons-Estel4,20,
  23. Gerald McGwin Jr21,
  24. Bernardo A Pons-Estel22
  25. on behalf of GLADEL
  1. 1Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú.
  2. 2Universidad Científica del Sur, Lima, Perú
  3. 3Universidad Nacional Mayor de San Marcos, Lima, Perú
  4. 4Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
  5. 5Servicio de Reumatología, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú
  6. 6Universidad Nacional de Rosario, Rosario, Argentina
  7. 7Servicio de Reumatología, Hospital Italiano and Fundación Dr. Pedro M. Catoggio para el Progreso de la Reumatología, Buenos Aires, Argentina
  8. 8Division of Rheumatology, Emory University School of Medicine, Atlanta, USA
  9. 9Hospital das Clinicas de Porto Alegre, Universidade Federal do, Rio Grande do Sul, Brazil
  10. 10Rheumatology Unit, Medical Faculty, Goiás Federal University, Goiânia, Brazil
  11. 11Divisao de Reumatologia, Faculdade de Ciencias Medicas, Universidade Estadual da Campinas, Campinas, Brazil
  12. 12Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
  13. 13Universidad CES, Medellín, Colombia
  14. 14Servicio de Reumatología, Centro de Investigaciones Médico Quirúrgicas (CIMEQ), La Habana, Cuba
  15. 15Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, México D.F., México
  16. 16Centro Médico ABC, Mexico D.F., Mexico
  17. 17Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico D.F., Mexico
  18. 18Servicio de Reumatología, Centro Nacional de Enfermedades Reumáticas, Hospital Universitario de Caracas, Caracas, Venezuela
  19. 19Hospital Central de San Cristóbal, San Cristobal, Venezuela
  20. 20Department of Autoimmune Diseases, Institut Clinic de Medicina I Dermatologia, Hospital Clinic, Barcelona, Catalonia, Spain
  21. 21Department of Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
  22. 22Hospital Provincial de Rosario, Rosario, Argentina
  1. Correspondence to Bernardo A Pons-Estel, Hospital Provincial de Rosario, Rosario, Argentina, Avenida del Huerto 1375, Rosario, 2000, Argentina; baponsestel{at}


Purpose To determine the association between the number of flares systemic lupus erythematosus (SLE) patients experience and damage accrual, independently of other known risk factors.

Methods SLE patients (34 centres, nine Latin American countries) with a recent diagnosis (≤2 years) and ≥3 evaluations were studied. Disease activity was ascertained with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and damage with the SLICC/ACR Damage Index (SDI). Flare was defined as an increase ≥4 points in the SLEDAI between two study visits. An ambidirectional case- crossover design was used to determine the association between the number of flares and damage accrual.

Results 901 patients were eligible for the study; 500 of them (55.5%) experienced at least one flare, being the mean number of flares 0.9 (SD: 1.0). 574 intervals from 251 patients were included in the case-crossover design since they have case and control intervals, whereas, the remaining patients did not. Their mean age at diagnosis was 27.9 years (SD: 11.1), 213 (84.9%) were women. The mean baseline SDI and SLEDAI were 1.3 (1.3) and 13.6 (8.1), respectively. Other features were comparable to those of the entire sample. After adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (SDI) OR 2.05, 95% CI 1.43 to 2.94, p<0.001 (OR 2.62, 95% CI 1.31 to 5.24, p=0.006 for severe and OR 1.91, 95% CI 1.28 to 2.83, p=0.001for mild-moderate).

Conclusions The number of flares patients experience, regardless of their severity, increases the risk of damage accrual, independently of other known risk factors.

  • Systemic Lupus Erythematosus
  • Disease Activity
  • Outcomes Research

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