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Is Your Practice Up to Date? New Guidelines for SLE Nephritis

d Michael Putman, MD, MSCI

Randomized controlled trials (RCTs) drive guidelines; guidelines drive clinical practice. Because updated guidelines lag trials by many years and dissemination of guidelines takes additional time, rheumatologists often practice “behind the data.” The 2024 ACR Guidelines for the Management of SLE Nephritis reaffirmed many of our typical practice patterns, including hydroxychloroquine for all, renin/angiotensin blockade, and favoring mycophenolate mofetil over cyclophosphamide.

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Methotrexate to Prevent RA, Clear as Mud

d Richard Conway, MBBChBAO, PhD

Intervention in individuals predisposed to develop RA, with a holy grail of prevention of RA, has long been a hot topic. The 4-year results of the TREAT EARLIER study, presented at Tuesday’s oral abstract session, show that methotrexate appears to prevent the development of RA in high risk ACPA- patients.

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Up-front Secukinumab in PsA?

d Richard Conway, MBBChBAO, PhD

We now have an absolute plethora of agents available for use in psoriatic arthritis (PsA). In contrast we have an almost complete lack of understanding of how best to optimise use of these agents – what is the right agent at the right time for the right patient. A study presented this week has given us some further information on the topic.

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Prof Petri reports the ff predictors of fracture in SLE: -older age -Caucasian race -female sex ⚠️ Prednisone (but not recent IM triamcinolone or IV methylpred) is a MAJOR risk factor. When possible, avoid prednisone! @RheumNow #ACR24 #ACRbest abs2679 @rheumarhyme https://t.co/q2NMRaYsAF

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sheila RHEUMarampa ( View Tweet)
All-caps abstract text throw-down by Michelle Petri re:fractures in SLE 😆 I keep saying this; our obsesssion with vitamin d is not commensurate w/reality It's. The. Prednisone. #ACR24 @RheumNow Abstr#2679 #ACRBest https://t.co/13luByNvYT

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Mike Putman EBRheum ( View Tweet)
What are the predictors of fracture in #SLE? 🦴Prednisone! Even at low doses ≤5mg 🦴Stroke 🦴Caucasian race 🦴Female 🦴Low BMD Try to avoid steroid use. If they are needed, IM triamcinolone or IVMP preferable to oral GC. Ab2679 #ACR24 @RheumNow

Mrinalini Dey DrMiniDey ( View Tweet)

Increased risk of mortality related to negative effects of GC use persists long after stopping and never return to pre-GC levels. #GCStewardship #ACR24 @RheumNow ABST#2673 https://t.co/5AwHDmvQGf

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Jiha Lee JihaRheum ( View Tweet)
How long is a long acting #intra-articular #steroid #injection in #knee #osteoarthritis? #IA steroids can be q3monthly #RCT of IA #fluticasone #propionate Was superior to #placebo Seemed to last approx 24 weeks ➡️ sub analysis in moderate pain, BMI<30 #ACR24 @RheumNow #2106 https://t.co/QBFCqXd1Q8

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Janet Pope Janetbirdope ( View Tweet)
PMR spotlight

JAKs and Other Drugs in PMR

d Richard Conway, MBBChBAO, PhD

This has been an interesting ACR meeting in terms of PMR updates. I would argue that we are still far too wedded to glucocorticoids only in the management of PMR. Yes, some patients will do fine with just glucocorticoids but we persist far too long with a glucocorticoid only strategy in others who clearly need an alternative as glucocorticoid adverse events multiply.

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Continuing or Stopping Low Dose Glucocorticoids in GPA Dr. Mike Putman reports about plenary session abstract 0774 (the TAPIR study) about how and when patients can stop steroids in GPA. #ACR24 https://t.co/OWqN0jmkc1 https://t.co/foOaVRtGiV

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Dr. John Cush RheumNow ( View Tweet)
A#2652 NEWTON study 🇫🇷 Retrosp cohort 51% relapse. Median @8.7 mos, dose 9mg pred Rf: limb art involv- HR 1.9 Pred taper speed not risk for relapse Most relapse -> incr GCs Toci 1/3 at dx, 50% stopped -61% d/c due to remission, 39% SEs -1/3 relapse after d/c @RheumNow #ACR24 https://t.co/NP0wieDmvo

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Eric Dein ericdeinmd ( View Tweet)
Peyrac et al. 211 GCA. Relapse in 52% at median 261 days (so 1st year). 83% on GCs at relapse, median dose 6.5mg pred. 36% relapse post-toc discontinuation, at median 133 days. 64% no relapse when toc stopped, at median 511 days @RheumNow #ACR24 Abstr#2652 https://t.co/NqtdDNGGoc https://t.co/mXD8x7O6Ww

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Richard Conway RichardPAConway ( View Tweet)
Peyrac et al. 211 GCA. Relapse in 52% at median 261 days (so 1st year). 83% on GCs at relapse, median dose 6.5mg pred. 36% relapse post-toc discontinuation, at median 133 days. 64% no relapse when toc stopped, at median 511 days @RheumNow #ACR24 Abstr#2652 https://t.co/NqtdDNGGoc https://t.co/mXD8x7O6Ww

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Richard Conway RichardPAConway ( View Tweet)
A#2648 PET for GCA Delayed imaging at 180 min improve dx performance for pts on GCs Optimal PET w/in 3 days of GC, most patients unable to do w/in that window Delay has sensitivity 92% even on prednisone - may be good tool for pts unable to get early PET/CT #ACR24 @RheumNow https://t.co/kxpNfRqkGN

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Eric Dein ericdeinmd ( View Tweet)
Important study in SLE: out of 590 pts with pericarditis, 20% had recurrence w/in 1 year Higher in early dx, younger pts, higher dx activity, & pred exposure Is prednisone risk confounding by indication? Or causative? #ACR24 @RheumNow @andreafava Abstr#2372 https://t.co/Seyi4F6weY

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Mike Putman EBRheum ( View Tweet)
Depressing finding re:glucocorticoid discontinuation in SLE No improvement over decades in rate of GC discontinuation; if anything, we start more GC than ever @AliDuarteMD help me out here; why haven't we made more progress? #ACR24 @RheumNow Abstr#2421 https://t.co/uzZATKPWVC

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Mike Putman EBRheum ( View Tweet)
Abstract 2503: Clofutriben (HSD-1 inhibitor) minimizes adrenal suppression. Adding clofutriben to prednisolone boosts ACTH & cortisol levels with fewer patients with suppressed morning cortisol (≤5.0 mg/dL) (34% vs 14%). @RheumNow #ACR24 #GCTox

Akhil Sood MD AkhilSoodMD ( View Tweet)

Class V #Lupus Nephritis usually takes longer to treat. Stay the course if no contraindications and taper steroids! - Dr A Askanase #ACR24 LN Guidelines @RheumNow https://t.co/4BBuAWi2da

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TheDaoIndex KDAO2011 ( View Tweet)
Instead of just JAKi, why don't we look at all our RA meds and MACE risk FAERS data & reporting odds ratios here: all the caveats of voluntary reporting, so don't put too much weight, but... prednisone. Don't forget pred is really not great for MACE! #ACR24 ABST1981 @RheumNow https://t.co/L9SlPZF2Jd

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David Liew drdavidliew ( View Tweet)
Systemic polyarteritis nodosa looks creepily/scarily beautiful on PET/CT. Look at that Christmas tree! but sensitivity can be affected by pred, & isn't great even without (48%). By itself, a good rule in test, but not a good rule out test. #ACR24 ABST1962 @MayoClinic @RheumNow https://t.co/y28J6VKja4

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David Liew drdavidliew ( View Tweet)

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