Treat to Target
Dr. Isenberg also discussed treat to target and its meaning for SLE. He emphasized damage in lupus predicts future damage and death, thus one treatment goal is to avoid damage. The target for SLE treatment, he explained, should be remission of systemic symptoms and organ manifestations as indicated by the lowest possible disease activity, but treatment of clinically asymptomatic patients should not be escalated if the patient has stable/persistent serological activity. Instead, healthcare providers should address the factors that negatively influence health-related quality of life, such as fatigue or pain.
Patients in remission should have no clinical features, no abnormal serologies and no requirement for steroids/immunosuppression. Unfortunately, even patients with full remission may flare, and one study suggested at least half of patients will flare over the course of a year.1 Another study of patients in full remission for three years found one in five went on to have a flare.2 Nevertheless, remission is an important treatment goal because patients who spend more than 50% of their observed time in a low disease activity state have significantly reduced organ damage.
For the most part, physicians have chosen the drugs to treat lupus based upon their anti-inflammatory properties. Now, however, lupus is recognized as a disease of waste disposal in which the DNA fragments appear to be picked up by antigen-presenting cells, Dr. Isenberg stated. This understanding should make it possible to develop therapies targeted at SLE-specific pathways.
Patients who spend more than 50% of their observed time in a lupus low disease activity state have significantly reduced organ damage.
Biologic Treatments
Meanwhile, rheumatologists have investigated the uses of many biologic treatments as therapies for lupus. Unfortunately, many of the clinical trials have failed. The exception is belimumab (Benlysta), an antibody against B lymphocyte stimulator, also known as B cell-activating factor, which has been approved by the U.S. Food and Drug Administration and the National Institute for Health and Care Excellence (NICE) for use in patients with SLE who have skin and joint disease. Long-term studies have confirmed belimumab is a safe drug that seems to be beneficial for about two-thirds of patients with lupus.
Dr. Isenberg concluded his presentation by stating the mortality rate for patients with lupus has clearly improved significantly over the past 50 years. Rheumatologists are now moving from an era of treatment serendipity to where it is becoming possible to introduce new therapies on a more rational basis. Unfortunately, thus far, except for belimumab and abatacept (anti-cytotoxic T-lymphocyte-associated antigen 4 [anti-CTLA-4]), biologic drugs have not been very successful in treating lupus, Dr. Isenberg stated.
So as we enter 2019, rheumatologists await the results of more, hopefully more successful, trials in SLE.
