Most studies agree that flares increase during pregnancy. Moreover, increased activity prepregnancy leads to increased activity during pregnancy. Thus, pregnancies should be monitored with frequent physician visits and lab testing, including urinalysis. Dr. Clowse emphasized, “You cannot assume that the obstetrician is following lupus.” SLE should be treated with hydroxychloroquine, azathioprine, and prednisone.
Novel Therapies for SLE
Richard A. Furie, MD, director of the Systemic Lupus Erythematosus and Autoimmune Disease Treatment Center at North Shore–Long Island Jewish Health System in Lake Success, N.Y., followed Dr. Clowse’s talk with a presentation on new drugs for SLE. He described the largest unmet needs for SLE to be severe extrarenal disease, lupus nephritis, damage prevention, and remission induction. He elaborated, “We do a terrible job with lupus nephritis … We need drugs to prevent damage.”
Unfortunately, he noted that, “doing lupus trials is very difficult.” This is because there is heterogeneity of manifestations that are further confounded by multiple background medications. Despite these challenges, there is currently unprecedented SLE clinical trial activity.
One therapeutic approach is a focus on the innate immune system and interferon alpha. Patients with SLE have elevated interferon alpha levels and serum from patients with SLE induces interferon gamma signatures. There is also evidence that antiinterferon alpha antibodies reduce SLE activity.
There have been two clinical trials to test type I interferon antagonists in patients with SLE. A phase I trial observed a reduction in interferon gene expression using a dose of 100 mg/week. A phase IIa trial noted a 40% reduction in interferon signature. Unfortunately, the reduction in interferon signature did not correspond with a clinical effect. Pharmaceutical companies have begun to target the interferon receptor (IFNAR). There are currently two trials underway: a phase I trial in scleroderma and a phase II study in SLE.
Dr. Furie explained that, “this is the era of lupus clinical trials.” He described studies using the B cell–directed therapies rituximab, ocrelizumab, epratuzumab, and belimumab. He concluded with a description of abatacept and its effect on lupus. While there are no conclusive data, the hope is that this heightened interest will result in improved treatment options for SLE.
Rheumatoid Arthritis: Treat to Target
Sergio Schwartzman, MD, associate attending physician at the Hospital for Special Surgery in New York City, described the initial 1958 diagnostic criteria for rheumatoid arthritis (RA), as well as the 1987 revised ACR classification criteria for RA. He then presented the newly established 2010 RA classification criteria and definition of remission. While acknowledging that they are imperfect, he explained that clinicians should “all be aware of these new definitions.” They allow for earlier disease recognition for clinical study and research and have implications for clinical practice.
