Insufficient hydroxychloroquine, excessive prednisone may hinder LLDAS, remission in lupus
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DESTIN, Fla. — Low disease activity and remission are achievable for patients with lupus if clinicians “minimize the prednisone” and administer adequate hydroxychloroquine, noted a speaker at the 2023 Congress of Clinical Rheumatology-East.
“We have proven that [Lupus Low Disease Activity State (LLDAS)] prevents organ damage, so this is an important treat-to-target,” Michelle Petri, MD, MPH, the director of the Lupus Center at Johns Hopkins University School of Medicine, told attendees during the hybrid meeting. “Obviously, remission is within LLDAS, and being in LLDAS protects against the major causes of mortality, such as myocardial infarction and end-stage kidney disease.”
In addition to protecting against cardiovascular and nephrological manifestations, patients in LLDAS are also protected against osteoporotic fractures, Petri said.
However, the first set of pitfalls for patients on the road to achieving LLDAS lie within therapy regimens.
“We are not using enough hydroxychloroquine,” Petri said. “We must make sure patients are on a therapeutic dose. Don’t be afraid to use our medications; if you don’t use it in a real dose, the patient cannot benefit from it.”
Additionally, Petri cautioned attendees against the use of prednisone, joking that the ‘P’ in ‘prednisone’ stands for ‘poison.’
“The bottom line is that patients should be receiving the lowest possible dose,” Petri said. “There is a reason we have immunosuppressives; there is a reason we have biologics use them.”
As with therapies, certain conditions sometimes stand in the way of patients’ goals of achieving LLDAS. Cardiovascular events, such as myocardial infarction and stroke, actually tend to peak within the first 2 years after lupus onset.
“This 2-year initial peak is a big problem, because we are barely getting to see the patient within the first 2 years,” Petri said.
Additionally, the large doses of prednisone that some patients receive in the early stage of their disease may be contributing to the problem, Petri noted.
“From the very beginning, you need to minimize the prednisone, and that is going to mean an earlier introduction of immunosuppressive drugs and biologics,” she said.
Chronic and end-stage kidney disease, as well as malignancy, can also be considerable roadblocks to achieving LLDAS.
“Remember, 70% of your African American patients, and 50% of your Caucasian patients will eventually have lupus nephritis,” Petri said.
To catch these complications early, Petri recommends performing the pertinent urinalysis tests at each visit.
“There are a whopping 17 different cancers that are significantly increased in lupus, not just non-Hodgkin lymphoma and leukemia,” Petri said. “Your patients must have all the age-appropriate malignancy screenings and you must maintain a high index of suspicion.”
Petri recognized that some easily modifiable social determinants of health may cause patients with lupus to have worse outcomes.
“Smoking is the biggest cause of lupus patients getting lung cancer,” Petri said. “That is one that we could strike from that malignancy list if we could just get our patients to stop smoking.”
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Petri M. Hurdles on the way to disease modification of lupus; LLDAS and remission. Presented at The Congress of Clinical Rheumatology East; May. 4-7, 2023; Destin, Florida (hybrid meeting).
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