Childhood lupus remission definitions emphasize corticosteroid cessation
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Key takeaways:
- New remission definitions for childhood SLE promote treat-to-target studies.
- The definitions align with those used in adult SLE and support collaborative research over a patient’s lifespan.
New definitions of remission specific to childhood systemic lupus erythematosus promote cessation of corticosteroids and could enable combined child-adult treat-to-target studies, according to an analysis published in Clinical Immunology.
The definitions were crafted by an international task force of pediatric subspecialists under the TARGET LUPUS research program.
“Despite advancements, standardized mortality rates remain significantly higher in childhood SLE compared to adult SLE,” Eve M.D. Smith, PhD, MBCHB, BSC, of the University of Liverpool, in the United Kingdom, told Healio. “Given the potential for improved outcomes with treat-to-target strategies, there was a compelling need to develop age-appropriate and disease-specific remission definitions tailored to pediatric patients with childhood SLE.”
To draft remission definitions specific to childhood SLE that are still sufficiently aligned with adult definitions, and enable treat-to-target trials comprising both groups, Smith and colleagues assembled an international task force. This group included pediatric subspecialists with significant expertise in childhood SLE, including 14 pediatric rheumatologists, two pediatric and adult rheumatologists, four nephrologists and an adult rheumatologist with experience developing treat-to-target approaches. Members hailed from Europe, Africa, Australia, Asia and North and South America.
Literature on previous remission definitions and targets was systematically reviewed. Task force members completed four Delphi surveys collecting preliminary opinions on the proper targets, steroid dosing and other aspects.
The results guided discussions to draft remission definitions during two virtual meetings in November 2021 and January 2022. The meetings included three young adults with childhood SLE and one parent of a patient, none of whom had voting privileges.
The task force ultimately decided to create two remission definitions: “cSLE clinical remission on steroids,” or cCR, and “cSLE clinical remission off steroids,” or cCR-0. According to the authors, the separate definitions recognize “strong dislike of corticosteroid treatment” among many patients and encourage their discontinuation.
After rounds of anonymous voting, the consensus criteria for the two childhood SLE remission definitions were as follows:
- Both require a cSLEDAI score of zero.
- Both require a physician global assessment score of 0.5 or less.
- Both require stable antimalarials, immunosuppressives and biologics.
- cCR requires a prednisolone dosage between 0.1 and 5 mg/kg/day, while cCR-0 requires zero.
The results represent “a significant step forward in addressing the unmet needs of children and teenagers” with childhood SLE, Smith told Healio.
“By establishing childhood SLE-specific remission definitions, clinicians now have standardized criteria to assess disease activity and treatment response in pediatric patients,” Smith said. “This not only facilitates clinical decision-making but also provides a framework for implementing treat-to-target strategies in clinical practice. Given the high burden of disease and increased risk of organ damage in childhood SLE, achieving and maintaining remission according to these definitions could potentially improve long-term outcomes and reduce morbidity and mortality in this vulnerable patient population.”
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