Systemic lupus erythematosus (SLE) can be categorized into three subsets based on disease activity: chronic active disease, relapsing-remitting disease, and clinical quiescent disease. Despite the fact that these disease definitions are based on the SLE Disease Activity Index (SLEDAI) or the SLEDAI-2000, there is disagreement on the exact definitions of a clinical quiescent condition. This has affected the variability of defining disease activity patterns, especially when defining remission.
To gain a better understanding of remission in recently diagnosed individuals with SLE, a group of researchers from the University of Padova conducted a study to quantify the prevalence of prolonged remission in patients with SLE and the effects of remission on organ damage, measured using the Systemic Lupus International Collaborating Clinics/ACR Damage Index for SLE (SDI). “It has to be highlighted that the majority of studies assessing remission in SLE included patients diagnosed with SLE from the 50’s to the 80’s, when diagnostic tools and treatments were less effective, leading to a worse long-term prognosis,” wrote Dr. Margherita Zen, in the team’s article, “Prolonged Remission in Caucasian Patients with SLE: Prevalence and Outcomes,” which was published in the journal Annals of the Rheumatic Diseases. These previous studies established that less than 10% of SLE patients experience prolonged remission.
The team used the Lupus Database in Padova, Italy, to identify 224 patients that met the inclusion criteria for the study. Patients were enrolled only if they had a score of 4 or more on the revised American College of Rheumatology Classification Criteria for SLE, were Caucasian, were diagnosed with SLE between 1990 and 2009, had an active disease status at the beginning of the study or were in remission for less than a year, and had at least three documented visits to the doctor’s office between 2009 and 2013. Finally, the team defined prolonged remission as a five-year consecutive period of no disease activity based on the SLEDAI-2000. Remission was further split into three categories: complete remission, clinical remission off corticosteroids (immunosuppressants and antimalarials allowed), and clinical remission on corticosteroids.
Statistical analysis revealed that 7.1% of patients achieved prolonged complete remission, 14.7% achieved prolonged clinical remission off corticosteroids, and 15.6% achieved prolonged clinical remission on corticosteroids. The majority (62.5%) did not achieve prolonged remission of any sort. The team found no association between achieving remission and age, gender, age at SLE onset, or disease duration. They did find an association between increased SDI and unremitted patients, with ~50% of unremitted patients experiencing increased organ damage and <50% of remitted patients experiencing an increase in organ damage.
Although more patients achieved prolonged clinical remission on corticosteroids, there was less organ damage in patients off corticosteroids. The researchers suggested two possible reasons. “First, patients in clinical remission on corticosteroids might have mild or subclinical manifestations not detected by the SLEDAI-2000, which require the maintenance of corticosteroid therapy,” wrote the authors. “Second, long-lasting corticosteroid therapy, even at very low doses, can itself represent a risk factor for comorbidity and damage.”
Overall, this study reports that approximately one-third of SLE patients experience remission. Remission is associated with less organ damage, especially when patients are not on corticosteroids. It was therefore suggested that SLE patients avoid long-lasting corticosteroid therapy and instead consider treat-to-target therapy.