An Important Shift in Lupus Care

Ronald F. van Vollenhoven, MD, PhD

Disclosures

July 21, 2014

In This Article

Critique of the T2T/SLE Recommendations

An important criticism of applying the treat-to-target concept in SLE is the fact that SLE is far more complex than hypertension. Therefore, it might be better to compare treating to target in SLE with treating to target in the entire field of cardiovascular disease prevention, where this strategy can be applied to multiple risk factors including hypertension, hypercholesterolemia, smoking (where the target is cessation), and obesity. In the T2T/SLE recommendations, it is implied (although not explicitly stated) that several targets could be selected for each patient, each with its own "target value," timeline, and intervention. This is more similar to a treat-to-target approach for overall cardiovascular disease prevention than that for hypertension alone.

Paradoxically, even though the T2T/SLE task force strongly supported the use of remission as a conceptual target in SLE, there is currently no widely accepted definition of remission in SLE. An international task force recently started a long-term project to achieve consensus and a proposed definition for remission in SLE. Meanwhile, the Asia-Pacific Lupus Collaboration has developed a Lupus Low Disease Activity State (LLDAS) score. Central to these efforts is the fact that although SLE is a highly heterogeneous disease on account of the many types of disease activity that may manifest in each individual, patients with no disease activity are much more homogeneous.

A further critical issue is whether treating to target does in fact result in better outcomes in SLE. This has not yet been proved; the equivalent trial to TICORA for RA has not been performed for SLE. There have been serious discussions on the possibility of performing a randomized trial (or perhaps a cluster-randomized trial, where the randomization is not at the level of the individual patient but at the level of the participating clinic or provider) comparing standard care and treat-to-target care. An electronic decision-making tool for this purpose, based on the T2T/SLE recommendations, is currently being developed.

The Time Is Now

In the process of developing T2T/SLE recommendations, experts have recognized that the key elements of treating to target are all possible to a lesser degree in SLE than in RA or in other diseases in which this approach has been applied successfully. Nevertheless, the introduction of treat-to-target principles to the care of patients with SLE cannot be postponed. Even if the work so far represents only a small portion of what still has to be done, it is undoubtedly the first important step toward a better treatment paradigm for SLE.

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