Are We Making Progress in Treating Lupus? Clinical Insights from Dr. Michelle Petri

Given new data that have emerged in recent years, Dr. Petri explained that a paradigm shift has occurred in which belimumab, the calcineurin inhibitor voclosporin and other treatments may be used in conjunction with mycophenolate mofetil or cyclophosphamide to prevent progression of lupus nephritis.

In terms of cancer risk in lupus, Zhang et al. performed meta analyses on 48 cohort studies and found an increased risk of cancer overall and of cancer-related death in patients with SLE compared with the general population. Moreover, SLE was a risk factor for 17 site-specific cancers, which include six digestive cancers, five hematologic cancers and cancer of the lung, larynx, cervix, vagina/vulva, kidneys, bladder, skin and thyroid.⁸

Regarding subtypes of lupus symptoms, Pisetsky et al. have helped define the concept of type 1 and type 2 symptoms of SLE. Type 1 symptoms include such features as rash, arthritis, alopecia and other manifestations that have a clear relationship to autoimmunity. Type 2 symptoms, such as fatigue, diffuse pain, cognitive dysfunction, sleep disturbance, anxiety/depression and brain fog, are non-inflammatory and don’t seem to respond well to immunosuppression.⁹ Recognition that both type 1 and 2 symptoms exist for many patients is essential to our ability to treat each patient as a whole person.

Although much work remains, Dr. Petri ended on a hopeful note. With advanced therapies, including CAR-T cell treatment, being explored in lupus each and every day, we can reasonably envision a future in which life for patients with lupus is longer, healthier and more fulfilling than what has been seen in years past.

---

Jason Liebowitz, MD, is an assistant professor of medicine in the Division of Rheumatology at Columbia University Vagelos College of Physicians and Surgeons, New York.

References

1. Franklyn K, Lau CS, Navarra SV, et al. Definition and initial validation of a lupus low disease activity state (LLDAS). Ann Rheum Dis. 2016 Sep;75(9):1615–1621.
2. Petri M, Magder LS. Comparison of remission and lupus low disease activity state in damage prevention in a United States systemic lupus erythematosus cohort. Arthritis Rheumatol. 2018 Nov;70(11):1790–1795.
3. Singh RR, Yen EY. SLE mortality remains disproportionately high, despite improvements over the last decade. Lupus. 2018 Sep;27(10):1577–1581. Epub 2018 Jul 17.
4. Nguyen Y, Blanchet B, Urowitz MB, et al. Association between severe non-adherence to hydroxychloroquine and SLE flares, damage, and mortality in 660 patients from the SLICC inception cohort. Arthritis Rheumatol. 2023 Jul 17.
5. Apostolopoulos D, Kandane-Rathnayake R, Raghunath S, et al. Independent association of glucocorticoids with damage accrual in SLE. Lupus Sci Med. 2016 Nov 22;3(1):e000157.
6. Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun;78(6):736–745.
7. Petri MA, Barr E, Magder LS. Development of a systemic lupus erythematosus cardiovascular risk equation. Lupus Sci Med. 2019 Oct 10;6(1):e000346.
8. Zhang M, Wang Y, Wang Y, et al. Association between systemic lupus erythematosus and cancer morbidity and mortality: Findings from cohort studies. Front Oncol. 2022 May 4;12:860794.
9. Pisetsky DS, Clowse MEB, Criscione-Schreiber LG, et al. A novel system to categorize the symptoms of systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2019 Jun;71(6):735–741.