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ObjectiveDrug-induced lupus (DIL) is an idiosyncratic side effect of treatments in which symptoms overlap with those of systemic lupus erythematosus (SLE). The spectrum of DIL constantly evolves with that of the pharmacopoeia. Here, we used VigiBase, the WHO global individual case safety reports (ICSRs) database, to identify the main drugs associated with DIL.MethodsWe analysed all ICSRs classified as ‘systemic lupus erythematosus’ according to the Medical Dictionary for Drug Regulatory Activities term (preferred term level) in VigiBase. The drugs considered in the analysis were those not used to treat SLE, with a positive lower end of the 95% credibility interval for the information component (IC025) ≥0, an indicator value for disproportionate Bayesian reporting.ResultsA total of 12 166 DIL ICSRs were identified using VigiBase. From those, 8163 ICSRs reporting on 118 suspected drugs with IC025 ≥0 were extracted. The median age at DIL onset was 49 years and the female to male sex ratio was 4.3. The median delay between start of suspected treatment and DIL occurrence was 172 days. DIL was reported as serious adverse event in 55.4%. Among the 118 suspected drugs, 42 had not been previously reported in association with DIL. The drugs associated with the highest number of DIL cases were infliximab, adalimumab, etanercept, procainamide and hydralazine.ConclusionThis study enables the identification of 118 drugs associated with DIL. The list of suspected drugs may prove useful to physicians when confronted with potential DIL cases.Trial registration numberNCT03480529.

From a 1-year survival of less than 50% before the discovery of glucocorticoids to over 90% at 10 years in most dedicated centres, the spectrum of SLE has profoundly evolved. Despite this improvement, several major challenges currently remain. The aim of this review is to analyse what are, according to us, the 10 most important contemporary challenges in the management of SLE. Among those are the need to treat to target to favour disease remission (or low disease activity), limit the use of glucocorticoids, derive more comprehensive tools for the evaluation of disease activity, develop more effective drugs (yielding successful trials), dissect the heterogeneity of the disease both at the molecular and genetic levels, identify relevant biomarkers for individualised treatment, manage fertility and pregnancy, tackle comorbidities such as cardiovascular risk, the prevention of infections and osteoporosis, improve the network of care (from the patients’ perspective), and favour a holistic approach (integrating fatigue, adherence to treatment, physical activity). Altogether, these 10 contemporary challenges in SLE may be considered as a roadmap for those involved in the daily care of patients with SLE, as well as for researchers who may wish to contribute to an improved management of this rare and complex disease.

Significant fatigue is reported by two-thirds of patients with SLE and severe fatigue by one-third. The assessment and treatment of fatigue remains a major challenge in SLE, especially in patients with no disease activity. Here, we suggest a practical algorithm for the management of fatigue in SLE. First, common but non–SLE-related causes of fatigue should be ruled out based on medical history, clinical and laboratory examinations. Then, presence of SLE-related disease activity or organ damage should be assessed. In patients with active disease, remission is the most appropriate therapeutic target while symptomatic support is needed in case of damage. Both anxiety and depression are major independent predictors of fatigue in SLE and require dedicated assessment and care with psychological counselling and pharmacological intervention if needed. This practical algorithm will help in improving the management of one the most common and complex patient complaints in SLE.

Objective Silica is an environmental substance strongly linked with autoimmunity. The aim of this study was to assess the prevalence of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and renal limited vasculitis, in a northeastern region of France and to evaluate whether there was a geospatial association between the localization of quarries in the region and the prevalence of these AAVs. Methods Potential AAV patients were identified using 3 sources: hospital records, immunology laboratories, and the French National Health Insurance System. Patients who resided in the Alsace region of France as of January 1, 2016 and who fulfilled the American College of Rheumatology criteria for GPA or the 2012 Chapel Hill Consensus Conference definitions for GPA or MPA were included. Incomplete case ascertainment was corrected using a capture–recapture analysis. The spatial association between the number of cases and the presence of quarries in each administrative entity was assessed using regression analyses weighted for geographic region. Results Among 910 potential AAV patients, we identified 185 patients fulfilling inclusion criteria: 120 patients with GPA, 35 patients with MPA, and 30 patients with renal limited vasculitis. The number of cases missed by any source as estimated by capture–recapture analysis was 6.4 (95% confidence interval [95% CI] 3.6–11.5). Accordingly, the estimated prevalence in Alsace in 2016 was 65.5 GPA cases per million inhabitants (95% CI 47.3–93.0), 19.1 MPA cases per million inhabitants (95% CI 11.3–34.3), and 16.8 renal limited vasculitis cases per million inhabitants (95% CI 8.7–35.2). The risk of AAV was significantly increased in communities with quarries (odds ratio 2.51 [95% CI 1.66–3.80]), and geographic‐weighted regression analyses revealed a significant spatial association between the proximity to quarries and the number of GPA cases (P = 0.039). In analyses stratifying the AAV patients by ANCA serotype, a significant association between the presence of quarries and positivity for both proteinase 3 ANCAs (P = 0.04) and myeloperoxidase ANCAs (P = 0.03) was observed. Conclusion In a region with a high density of quarries, the spatial association between the presence of and proximity to quarries and the prevalence of AAVs supports the idea that silica may have a role as a specific environmental factor in this disease.

Hughes-Stovin syndrome requires immediate therapeutic decision, with an important risk of the anticoagulation. High dose steroids and in most cases, intensive immunosuppressive therapies are required such as cyclophosphamide.

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BackgroundFatigue is an important issue in systemic lupus and has a major impact on quality of life of the patients. Data are controversial about the factors associated with this complex symptom.1 ObjectivesTo identify the factors associated with fatigue and severe fatigue in patients with systemic lupus erythematosus (SLE) in a large cohort using a multivariate model to precise the importance of each parameter in this multidimensional symptom.MethodsWe used the LBBR data base, a German French data base of SLE patients. All patients fulfilled the 1997 ACR criteria for SLE. The Fatigue Scale for Motor and Cognitive Functions (FSMC) was used to assess fatigue and severe fatigue. The depression and anxiety were measured with Hospital Anxiety and Depression Scale (HADS). Tests were performed at sampling.ResultsA total of 570 patients were included (89.1% female). The median age was 42 years (QR25–75: 34–52). The median value of the SELENA-SLEDAI was 2 (QR25–75: 0–4) and 136 patients had a SELENA-SLEDAI score >6. Fatigue was reported by 386 patients (67.7%) including severe fatigue by 209 (36.7%). In univariate analysis among the individual components of the SLEDAI arthritis (p=0.003) and oral ulcers (p=0.002) were associated with severe fatigue.In multivariate analysis fatigue was strongly associated with anxiety (OR: 4.49 [95%CI: 2.60–7.77], p<0.0001) and depression (OR: 4.72 [95%CI: 1.39–16.05, p=0.01]. It was also associated with age at sampling (OR: 1.01 [95%CI: 1.00–1.03, p=0.03] per 1 year increase), SLEDAI (OR: 1.05 [95%CI: 1.00–1.12, p=0.043] per 1 SLEDAI point increase) and glucocorticoids treatment (OR: 1.54 [95%CI: 1.00–2.38, p=0.04]). It was not associated with physical activity.Severe fatigue was strongly associated with depression (OR:6.87 [95%CI: 3.12–15.11], p<0.0001) and anxiety (OR: 3.80 [95%CI: 2.46–5.87], p<0.0001) but not with SLEDAI or physical activity.ConclusionsFatigue is a common symptom in SLE patients and is strongly associated with anxiety and depression. While remission remains an important therapeutic target, these manifestations should also be taken care of with psychological counselling and pharmacological intervention, when needed.Reference[1] Cleanthous S, Tyagi M, Isenberg DA, Newman SP. What do we know about self-reported fatigue in systemic lupus erythematosus?Lupus. 2012Apr;21(5):465–76Disclosure of InterestNone declared