Prolonged Remission in SLE Revisited: An Old Wine in a New Bottle

Abstract

To achieve sustained remission is the ultimate goal of any maintenance treatment used in systemic lupus erythematosus (SLE) — as well as the dream of any clinician in charge of patients with SLE. While in other autoimmune diseases, such as rheumatoid arthritis, it is easier to identify which patients achieved remission or low disease activity levels, the concept of remission is more difficult to define and harder to achieve in SLE, owing to the heterogeneity of this condition, the multiple organs affected, and the many activity scores used. In this issue of The Journal , Steiman, et al 1, from the University of Toronto Lupus Clinic, interestingly revisit the concept of sustained and prolonged remission in patients with SLE followed between 1970 and 2011 using a standardized protocol at clinic visits. The authors conducted a study focused on prolonged clinical remission (clinically quiescent), with or without serological activity, in a cohort including more than 1600 SLE patients with a very long followup (mean disease duration, 21 yrs). Of interest, only around 2% of patients achieved prolonged (at least 5 yrs) clinical remission, without any underlying immunosuppressive drug (except for antimalarials). An additional subset of patients who achieved remission while taking medical treatment are described. The authors used very strict definition criteria for serologically and clinically quiescent disease: at least a 5-year period without evidence of clinical activity [SLE Disease Activity Index 2000 (SLEDAI-2K) = 0]. Clinically quiescent but serologically active disease allowed SLEDAI-2K scores ≤ 4, positive anti-dsDNA antibody and/or hypocomplementemia only. Patients with prolonged remission had a lower burden of disease activity and disease damage. Further, the authors made an attempt to identify predictors of prolonged remission. Interestingly, regression models revealed that patients with late disease onset and those with less skin disease were more likely to achieve … Address correspondence to Dr. Gomez-Puerta, Division of Rheumatology, Immunology and Allergy, PBB-B3; Section of Clinical Sciences, Brigham and Women’s Hospital, 221 Longwood Ave., 3rd floor, Boston, Massachusetts 02115, USA. E-mail: jgomezpuerta{at}mail.harvard.edu