What Counts as Remission in SLE? Task Force Releases Recommendations

The new recommendations for systemic lupus erythematosus (SLE) use disease activity index scores and evaluator’s global assessment measures, but they do not include serology.

A key task force has released its recommendation for how to define remission in patients with systemic lupus erythematosus (SLE).

The recommendations are aimed at unifying treatment targets and assisting investigators by attaching a clear definition to the term. The recommendations were published in Lupus Science & Medicine.

The recommendations were created by the Definitions of Remission in SLE (DORIS) Task Force, which has been working in 2015 to achieve a better consensus of what should qualify as remission in SLE.

Corresponding author Ronald F. van Vollenhoven, MD, PhD, of the Amsterdam Rheumatology and Immunology Center, in the Netherlands, and colleagues, said investigators have long believed that a treating-to-target (T2T) approach would be beneficial for patients with SLE, just as it has helped improve care for conditions like psoriatic arthritis and rheumatoid arthritis. However, in order for such a strategy to be implemented, they said investigators would first need to define an appropriate target.

In 2016, the DORIS task force released initial recommendations, amounting to a framework for a future definition. The initial recommendations called for the use of a validated instrument along with the use of the Evaluator’s Global Assessment. Other questions, such as whether serological data should factor into the definition, were left open.

Since then, the entire task force has met twice more, and its steering committee has met on several more occasions, van Vollenhoven and colleagues said. They eventually arrived at a set of recommendations using existing studies and several SLE-specific data sets.

The new recommendation calls for remission to be defined as a score of 0 on the SLE disease activity index (SLEDAI) and an Evaluator’s Global Assessment score of <0.5 (0-3). Patients may be on stable antimalarials, immunosuppressive drugs, biologics, and/or low-dose glucocorticoids (prednisolone of 5 mg/day or less).

The task force chose not to include serological measures in its definition. They reported that, while abnormal serology or serological changes were found in some studies to be predictive of imminent flares or future relapse, “in most studies, abnormal serology was not an independent predictor of damage, late morbidity or mortality.”

Van Vollenhoven and colleagues said they considered practicality as part of their deliberations. For instance, they believed that a definition of remission that required a patient to be on no therapy would be too stringent, resulting in a group of patients in “remission” that would be too small to be meaningful.

The task force also said that within their recommendations, it was possible to draw a line between what counts as remission, and what would be considered “preferable.” It would be preferable for a patient to no longer require glucocorticoids, they said.

“However, the question before the task force was not so much what the preferred state of the patient should be, but what definition would be most useful to be deployed operationally to correspond with the concept of remission,” the authors wrote.

The investigators also discussed the question of the value of a definition of remission when there is already a definition for low disease activity (LDA). Though they said patients in remission under their definition would comprise a significant subset of patients with LDA, van Vollenhoven and colleagues said they believe it is important to be able to clearly identify patients in remission.

“The essential defining difference between remission and LDA in the context of this task force is the face validity: the state of remission from the patient’s perspective being fundamentally different from having an LDA (but not remission),” they wrote.

Reference

van Vollenhoven RF, Bertsias G, Doria A, et al. 2021 DORIS definition of remission in SLE: Final recommendations from an international task force. Lupus Sci Med. 2021;8(1):e000538. doi:10.1136/lupus-2021-000538