Diagnosis and treatment of lupus erythematosus

  Diagnosis of lupus erythematosus: First of all, let’s look at the classification criteria of SLE: the sensitivity of the 2012 SLICC classification criteria is 94% and the specificity is 92%, which is more sensitive than the 1997 classification criteria, while the specificity has not decreased significantly. So what is the difference in sensitivity of the 1997 classification criteria? The results of a study conducted in 17 centers worldwide, which included 2055 patients with SLE, suggest that the sensitivity of the two classification criteria converge as the disease duration increases, while the difference is most pronounced in patients with shorter disease duration, especially those ≤5 years.  T to T treatment of lupus: How can we determine whether the treatment goal has been achieved? For this purpose, we propose a definition of remission. The international expert panel consensus defines SLE remission as a state of persistent absence of symptoms, signs and abnormal serological findings. This includes (i) treatment-free remission: patients have no lupus treatment other than maintenance low-dose hydroxychloroquine; and (ii) treatment remission: patients are allowed to receive maintenance doses of hydroxychloroquine, stable low-dose hormones (prednisone <5 mg/d), maintenance doses of immunosuppressive agents and/or stable (maintenance dose) biologic therapy.  The following views were strongly endorsed by experts: (i) remission is the desired outcome in the treatment of lupus patients; (ii) lupus remission requires at least the absence of major signs and symptoms of lupus; (iii) lupus remission is different from cure; (iv) lupus remission is different from low disease activity; (v) lupus patients in sustained remission have a lower likelihood of adverse outcomes; (vi) serologic activity usually refers to anti-dsDNA positivity and/or hypocomplementemia (vii) antimalarial therapy does not prevent patients from achieving remission; (viii) remission cannot be considered achieved in medium- to high-dose steroid hormone therapy.  Is remission the only goal of lupus treatment? A global multicenter study led by Australian scholars proposed the concept of LLDAS (Lupus Low Disease Activity State) as a more satisfactory outcome of lupus treatment.LLDAS is defined as: in terms of disease activity: ①SLEDAI-2K≤4, no activity in vital organs/systems (kidney, CNS, heart, lung, vasculitis, fever), no active manifestations in the hematological system and gastrointestinal tract. (ii) no manifestation of new lupus activity compared to the previous assessment; (iii) SELENA-SLEDAI physician's overall assessment (PGA0-3) ≤1; for immunosuppressive agents: (i) prednisolone acetate (or equivalent hormone) ≤7.5 mg/day; (ii) routine maintenance doses of immunosuppressive agents and biologics that have been marketed. The current study concluded that there is a clear correlation between LLDAS and patients' disease recurrence alone, and that patients reaching LLDAS not only have fewer recurrences, but also reach a smaller proportion of severe recurrences. In addition, fewer relapses and less immunosuppression is required to achieve LLDAS.  Advances in the diagnosis and treatment of lupus nephritis: We mainly share the consensus on the diagnosis and treatment of lupus nephritis treatment in Asia. Mild, moderate and severe lupus nephritis need to be classified. Focus on the Asian consensus guidelines for the treatment of severe lupus nephritis: ① induction phase: hormone (e.g., prednisolone 0.8 mg/kg/day) combined with morte-macrolimus/cyclosporine; ② renal biopsy suggesting crescent ≥10% or worsening renal function, hormone shock (e.g., methylprednisolone 0.5-1.0 g/day x 3d); ③ unless no improvement, usually taper hormone after 2 weeks, <20 mg/day after 3 months, and ≤7.5 mg/day after 6 months); ④IV CYC is recommended in case of poor compliance; ⑤ morte-macrolimus dose 1.5-2 g/day, if morte-macrolimus is used as induction therapy prerequisite, the duration of treatment should be ≥24 months; ⑥Calcium phosphatase inhibitors can be considered as the following: a as induction therapy in combination with hormones (not tolerating morte-macrolimus or cyclophosphamide), b as maintenance therapy In particular, renal biopsy with membranous manifestations and persistent proteinuria even after induction phase treatment; (vii) Patients with simple V lupus nephritis should be treated with hormones combined with immunosuppressive agents when proteinuria ≥ 2 g.