Thursday, 17 Jan 2019

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CRA Recommendations for Lupus Assessment and Monitoring

A Canadian Rheumatology Association SLE Working Group was established to develop recommendations for the assessment of people with systemic lupus erythematosus (SLE). 

A panel that included 23 adult rheumatologists, 4 pediatric rheumatologists, 1 immunologist, 4 general internal medicine and rheumatology trainees, and a patient representative, used GRADE methodology to assess the literature and develop guidelines.

In all, there were 15 recommendations for assessing and monitoring. These are exerpted below and address diagnosis, disease activity, damage assessment, disease activity measures score and infection risk reduction

Best practice for the assessment and monitoring of systemic lupus erythematosus (SLE) in Canada

  1. Rheumatologist: We recommend that all adult patients suspected of SLE be referred to an SinLE specialist, most often a rheumatologist.
  2. Disease activity: For adult and pediatric patients with SLE, we suggest assessing disease activity with a validated instrument of disease activity during baseline and followup visits.
  3. Damage: For adult and pediatric patients with SLE, we suggest assessiing disease damage annually with a validated measure.
  4. Cardiovascular (CV) risk: a CV risk assessment should be performed in adult patients upon diagnosis of SLE, including indicators of obesity, smoking, hypertension, diabetes, and dyslipidemia be measured upon diagnosis of SLE, and be reassessed periodically.
  5. In adults with SLE, we suggest that carotid ultrasonography not be routine in the CV risk assessment.
  6. Osteoporosis: adult SLE we suggest assessing for risk of osteoporosis and fractures every 1 to 3 years using a including measuring bone mineral and OP risk factors.
  7. Vitamin D: For all adults with SLE, we suggest screening for 25-hydroxy vitamin D levels.
  8. Osteonecrosis: all adult and pediatric SLE patients, in particular those who have a history of glucocorticoid exposure, receive information about the symptoms of osteonecrosis.
  9. For women with SLE, we recommend testing for anti-Ro and anti-La antibodies prior to pregnancy or during the first trimester.
  10. For pregnant women with SLE, we suggest uterine and umbilical Doppler studies be performed in the second or third trimester, or with a suspected flare.
  11. For women with prior or active lupus nephritis who are pregnant, we suggest measuring serum creatinine and urine protein to creatinine evidence  ratio every 4–6 weeks, or more frequently if indicated. We also  suggest blood pressure and urinalysis be measured prior to pregnancy and every 4–6 weeks until 28 weeks, every 1–2 weeks until 36 weeks,  and then weekly until delivery.
  12. In sexually active female adult SLE patients, we suggest annual cervical cancer screening rather than screening every 3 years, at least up to the age of 69.
  13. We recommend that adults and children with SLE receive vaccination annual inactivated influenza vaccination.
  14. For adult and pediatric patients with a diagnosis of SLE, we recommend screening for HbsAg. 
  15. For adults and pediatric SLE patients we recommend screening for HCV. 

Strong recommendations were made for cardiovascular assessments and measuring anti-Ro and anti-La antibodies in the peripartum period. A strong recommendation was made for annual influenza vaccination.

Even though most of the supportive evidence was mostly of low to moderate quality, with more conditional than strong recommendations, these guidelines are novel in using GRADE to addressi SLE monitoring. More research on pediatric SLE populations and patient input and preferences are needed.

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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