ACR: Lupus Prognoses Improve With Better Use of Standard Therapies

[Guest guest]

ACR: Lupus Prognoses Improve With Better Use of Standard Therapies





By Lynne , MedPage Today Staff Writer

Reviewed by Jasmer, MD; Assistant Professor of Medicine,

University of California, San Francisco



MedPage Today Action Points

Be aware that the prognosis for lupus has improved significantly

since 1970, with much of that improvement attributable to more

aggressive treatment, including more use of immunosuppressives, and

lower cumulative doses of steroids.

Explain to patients that several drugs are being investigated for

lupus treatments but those drugs are not yet approved for lupus.

This study was published as an abstract and presented at a conference

either as an oral or poster presentation. These data and conclusions

should be considered to be preliminary as they have not yet been

reviewed and published in a peer-reviewed publication.

Review

SAN DIEGO, Nov. 21 - The health and survival of lupus patients has

steadily improved over the past 35 years despite the fact that no new

lupus treatments have been approved since 1970.

The average annual mortality rate for lupus during the period from

1997 to 2005 was 1.8%, down from 14% during the period 1970 to 1978,

a highly significant (P<0.0001) decline, Canadian researchers

reported at the American College of Rheumatology annual meeting here.

Similarly, the predicted death rate for lupus in 2005 dropped to 3.2

times the expected mortality for age- and sex-matched healthy

individuals, compared with 14.4 times that of the healthy population

in 1970, added a team from the Center for Prognosis Studies in the

Rheumatic Diseases at Toronto Western Hospital.

The credit for the steady improvement goes to a trio of factors,

according to Murray Urowitz, M.D., and colleagues. These are

aggressive treatment, more use of immunosuppressants, and a reduction

in the cumulative dose of steroids.

They analyzed records from 1,184 lupus patients (representing 10,744

patient-years) who had been followed with clinical and laboratory

evaluations every two to six months from 1970 to 2005. They found

that survival rates in patients with lupus have been improving, and

the overall level of disease activity seems to be improving as well.

" These data indicate that more aggressive use of immunosuppressants

and other therapies, even with reduced steroid use, may be having an

impact, " said Dr. Urowitz.

He pointed out that there has been a sea change in the prognosis for

lupus patients over the last 30 years. " We know people are not dying

of lupus as early and signs seem to suggest that we are coming up

with better algorithms for treatment, " he said.

Dr. Urowitz and his colleagues reviewed records form 228 lupus

patients treated from 1970 to 1978; 363 patients treated 1979 to

1987; 260 treated from 1988 to 1996; and 333 patients treated from

1997 to 2005.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder

that affects mostly women, particularly during the childbearing years

(ages 14 to 45), and it is prevalent -- and often more severe -- in

people of African, Asian, Native American, and Hispanic descent.

Conservative treatment for lupus includes topical creams, anti-

malarial drugs, and non-steroidal anti-inflammatory drugs (NSAIDs).

More aggressive therapy for patients with severe disease often

includes the use of high-dose steroids and other immunosuppressive

and cytotoxic drugs, such as Imuran (azathioprine), Cytoxan

(cyclophosphamide), methotrexate, and Cellcept (mycophenolate

mofetil). The researchers also reported a " dramatic " increase in the

use of Plaquenil (hydrochloroquine) over the three decades studied.

Dr. Urowitz added that Plaquenil is " sort of the standard of care now. "

During the 35 years studied, steroid use was fairly constant but the

cumulative doses of steroids decreased, while the use of

immunosuppressives increased.

At the same time, the lupus population has shifted. " The percentage

of pure Caucasians has decreased (in our population), while the

number of black and Chinese have increase, " Dr. Urowitz said.

That racial shift makes the improvement in outcome even more

striking, he said, because " we would expect, if anything, that lupus

would get worse with this population shift because the literature

indicates blacks and Chinese have a more severe form of lupus than

Caucasians. But that was not, in fact, what happened. "

While the good news is that lupus patients are dying much less

frequently than they used to die, the mortality rate is still more

than three times that for the normal population. Dr. Urowitz pointed

out. " Lupus patients are dying less frequently, they have less

disease, and perhaps the reason is that they are presenting with less

active disease, and are being treated with less cortisone and more

other drugs, " he said.

But even though patients are presenting with less active disease, Dr.

Urowitz insisted that the improvement in lupus patients' health and

survival was not due to earlier diagnosis and treatment.

And while, the past 35 years have yielded no new lupus therapies,

that may be changing, he said.

Several drugs are being investigated in ongoing clinical trials

including Rituxan (rituximab) LymphoStat-B (belimumab), Gleevec

(imatinib), IL-6 (tocilizumab), Riquent (abetimus, a toleragen), and

the fusion protein TACI-Ig.

Primary source: American College of Rheumatology