Remission in systemic lupus erythematosus: testing different definitions in a large multicentre cohort

Abstract

ObjectivesRemission in systemic lupus erythematosus (SLE) is defined through a combination of ‘clinical SLE Disease Activity Index (cSLEDAI)=0’, ‘physician's global assessment (PGA) <0.5’ and ‘prednisone (PDN) ≤5 mg/day’. We investigated the performance of these items, alone or in combination, in defining remission and in predicting SLICC/ACR Damage Index.MethodsWe tested seven potential definitions of remission in SLE patients followed-up for ≥5 years: PDN ≤5 mg/day; PGA <0.5; cSLEDAI=0; PGA <0.5 plus PDN ≤5 mg/day; cSLEDAI=0 plus PGA <0.5; cSLEDAI=0 plus PDN ≤5 mg/day; cSLEDAI=0 plus PDN ≤5 mg/day plus PGA <0.5. The effect of these definitions on damage was evaluated by Poisson regression analysis; the best performance was identified as the lowest Akaike and Bayesian information criterion (AIC and BIC). Positive and negative predictive values in identifying no damage increase were calculated.ResultsWe included 646 patients (mean±SD disease duration 9.2±6.9 years). At multivariate analysis, ≥2 consecutive year remission according to all definitions protected against damage (OR, 95% CI: PGA <0.5 0.631, 0.444 to 0.896; cSLEDAI=0 0.531, 0.371 to 0.759; PGA <0.5 plus PDN ≤5 mg/day 0.554, 0.381 to 0.805; cSLEDAI=0 plus PGA <0.5 0.574, 0.400 to 0.826; cSLEDAI=0 plus PDN ≤5 mg/day 0.543, 0.376 to 0.785; cSLEDAI=0 plus PDN ≤5 mg/day plus PGA <0.5 0.532, 0.363 to 0.781, p<0.01 for all), except PDN ≤5 mg/day, which required four consecutive years (OR 0.534, 95% CI 0.325 to 0.877, p=0.013). Positive and negative predictive values were similar; however, cSLEDAI=0 showed the best performance (AIC 1082.90, BIC 1109.72, p<0.0001). Adding PGA <0.5 and/or PDN ≤5 mg/day to cSLEDAI=0 decreased remission duration (−1.8 and −1.5 year/patient, respectively) without increasing cSLEDAI=0 performance in predicting damage accrual.ConclusionscSLEDAI=0 is the most attainable definition of remission, while displaying the best performance in predicting damage progression in the short-to-mid-term follow-up.

2021 DORIS definition of remission in SLE: final recommendations from an international task force

“…In an Italian multicentre study based on a larger cohort of patients (n=646), the performance of seven different definitions of remission was tested. 20 Clinical SLEDAI=0 had the best performance in terms of protection against damage compared with the other definitions including PGA ≤0.5 or prednisolone ≤5 mg/day. ► Data from the Asia-Pacific Lupus Collaboration cohort were reviewed.…”

Prevalence, Predictors, and Prognostic Benefits of Remission Achievement in Patients With Systemic Lupus Erythematosus: A Systematic Review

“…Controversies exist (9,15), however, and to date, only a few clinical trials have evaluated the impact of treatment strategy on rates of remission. Recently, research comparing different remission definitions was conducted by Saccon et al (48). They indicated that a clinical SLEDAI score of 0 is an easy‐to‐achieve definition with the best performance in predicting damage progression compared to other definitions, including PhGA and low‐dose prednisone.…”

11 Remission and low disease activity: the new targets for treatment

“…In a post-hoc analysis carried out in patients enrolled in BLISS-52 and BLISS-76, remission and LDA were able to discriminate response to belimumab 10 mg/kg from placebo. 5 6 Notably, clinical (c) SLEDAI-2K=0 was the best discriminator 6 and, importantly, in a recent multicentre cohort study including 646 patients, cSLEDAI=0 had the best performance in predicting damage accrual compared with all other definitions of remission. 7 In real-life the proportion of patients who can achieve a stable low lupus disease activity state (LLDAS) and remission was higher than that obtained in randomised controlled trials, as shown in two recent studies.…”