Treat-to-Target in Systemic Lupus Erythematosus
Treat-to-Target in Systemic Lupus Erythematosus
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.
Over the past 50 years, the therapeutic strategy for some of the most common chronic diseases has evolved from a symptom-based to a target-based approach, under the influence of evidence that such approaches yield superior outcomes. For example, in the management of hypertension, targeting suitably chosen values for systolic or diastolic blood pressure yields long-term reductions in the risks for cardiovascular diseases. Likewise, in the management of diabetes, targeting specific values for blood-glucose, measured directly or indirectly by haemoglobin A1c, has resulted in major improvements in long-term prognosis.
In the rheumatic diseases, where symptomatology is often the predominant concern on the patient's part, it is less intuitive to investigate targeted approaches. Nonetheless, in the management of rheumatoid arthritis (RA), several randomised clinical trials provided evidence that such targeted approaches yielded superior outcomes in terms of clinical course, long-term damage and functional status. As a result, treat-to-target recommendations were developed for RA, prompting further investigations and cautious implementation of such approaches. More recently, treat-to-target recommendations for the spondyloarthropathies were also published.
Systemic lupus erythematosus (SLE) is a chronic disease where treatment is typically long-term or even life-long. The disease engenders significant symptomatologies, which are often the principal drivers of the patient's medical need for interventions, however, not all disease activity is perceptible as characteristic symptoms. SLE is also associated with the progressive accumulation of irreversible organ damage, which has been shown to be a predictor of further damage, additional morbidity and early mortality. Based on these considerations, it was reasonable to ask the question if the principles of treating-to-target could be applied to the management of SLE as well. An international task force was gathered to investigate this question and formulate recommendations aimed at improving the management of SLE in clinical practice through target-based approaches. The task force directed a systematic literature review (SLR), which served as the evidence base, and developed a set of overarching principles and recommendations for treating-to-target in SLE.
Abstract and Introduction
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.
Introduction
Over the past 50 years, the therapeutic strategy for some of the most common chronic diseases has evolved from a symptom-based to a target-based approach, under the influence of evidence that such approaches yield superior outcomes. For example, in the management of hypertension, targeting suitably chosen values for systolic or diastolic blood pressure yields long-term reductions in the risks for cardiovascular diseases. Likewise, in the management of diabetes, targeting specific values for blood-glucose, measured directly or indirectly by haemoglobin A1c, has resulted in major improvements in long-term prognosis.
In the rheumatic diseases, where symptomatology is often the predominant concern on the patient's part, it is less intuitive to investigate targeted approaches. Nonetheless, in the management of rheumatoid arthritis (RA), several randomised clinical trials provided evidence that such targeted approaches yielded superior outcomes in terms of clinical course, long-term damage and functional status. As a result, treat-to-target recommendations were developed for RA, prompting further investigations and cautious implementation of such approaches. More recently, treat-to-target recommendations for the spondyloarthropathies were also published.
Systemic lupus erythematosus (SLE) is a chronic disease where treatment is typically long-term or even life-long. The disease engenders significant symptomatologies, which are often the principal drivers of the patient's medical need for interventions, however, not all disease activity is perceptible as characteristic symptoms. SLE is also associated with the progressive accumulation of irreversible organ damage, which has been shown to be a predictor of further damage, additional morbidity and early mortality. Based on these considerations, it was reasonable to ask the question if the principles of treating-to-target could be applied to the management of SLE as well. An international task force was gathered to investigate this question and formulate recommendations aimed at improving the management of SLE in clinical practice through target-based approaches. The task force directed a systematic literature review (SLR), which served as the evidence base, and developed a set of overarching principles and recommendations for treating-to-target in SLE.
