Treat-to-target in systemic lupus erythematosus: recommendations from an international task force

Abstract

The principle of treating-to-target has been successfully applied to many diseases outside rheumatology and more recently to rheumatoid arthritis. Identifying appropriate therapeutic targets and pursuing these systematically has led to improved care for patients with these diseases and useful guidance for healthcare providers and administrators. Thus, an initiative to evaluate possible therapeutic targets and develop treat-to-target guidance was believed to be highly appropriate in the management of systemic lupus erythematosus (SLE) patients as well. Specialists in rheumatology, nephrology, dermatology, internal medicine and clinical immunology, and a patient representative, contributed to this initiative. The majority convened on three occasions in 2012-2013. Twelve topics of critical importance were identified and a systematic literature review was performed. The results were condensed and reformulated as recommendations, discussed, modified and voted upon. The finalised bullet points were analysed for degree of agreement among the task force. The Oxford Centre level of evidence (LoE, corresponding to the research questions) and grade of recommendation (GoR) were determined for each recommendation. The 12 systematic literature searches and their summaries led to 11 recommendations. Prominent features of these recommendations are targeting remission, preventing damage and improving quality of life. LoE and GoR of the recommendations were variable but agreement was >0.9 in each case. An extensive research agenda was identified, and four overarching principles were also agreed upon. Treat-to-target-in-SLE (T2T/SLE) recommendations were developed by a large task force of multispecialty experts and a patient representative. It is anticipated that 'treating-to-target' can and will be applicable to the care of patients with SLE.

Analysis of Complete Remission in Systemic Lupus Erythematosus Patients Over a 32‐Year Period

“…Further studies have shown that patients with a prolonged SACQ disease accumulate less damage, supporting the idea of managing them with close monitoring without therapy during this period (15,16).…”

Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus: A Systematic Review of Clinical Practice Guidelines

“…Long-term monitoring was recommended (10,14), with 3-6 month assessment for mild disease and increased frequency for patients with severe active disease and in pregnancy (10). Patients with nonactive SLE and no damage or comorbidity could be assessed every 6 to12 months with additional evaluation prior to pregnancy, surgery, transplantation, use of estrogen-containing medication, or occurrence of a new neurologic or vascular event (11).…”

“…Six guidelines provided recommendations on monitoring disease activity, disease damage, and quality of life (10)(11)(12)(13)(14)(15).…”

Immunosuppressive Treatment for Lupus Nephritis: Long-Term Results in 178 Patients

“…Since damage predicts subsequent death, prevention of damage accrual should be a major therapeutic goal in SLE. SELENA SLEDAI Disease Assessment Scale and SLICC/ACR Damage Index are recommended for assessment of SLE activity and damage [8]. …”