Navigating the Path to SLE Remission Save

Thank you so much for joining us today as we discuss how to navigate the path to SLE remission. This discussion is sponsored by AstraZeneca Medical Affairs and is intended for healthcare providers. Both speakers have been compensated for their time. My name is Doctor. Christina Arians from the Oklahoma Medical Research Foundation, where I am a clinical associate professor.

I am joined by Doctor. Anka Askenaz, who will introduce herself.

Hi. I'm Anka Askenaz. I'm professor of medicine and director of the Lupus Center at Columbia University in New York City. Additionally, I'm part of the core team, the oversight for the development of twenty twenty five ACR guidelines for the treatment of SLE.

Thank you for joining us today for this discussion on achieving DORS remission in SLE. I wanted to start with some definitions so we're all on the same page. DORS stands for definition of remission in SLE and includes no disease activity, a clinical SLEI two ks of zero, a physician global assessment less than 0.5, prednisone or equivalent less than or equal to five milligrams per day, and stability of antimalarials, immunosuppressive agents, or biologics. The LLDAS stands for lupus low disease activity state, and it includes a Slido two ks of less than or equal to four, a Salinas Slido physician global assessment less than or equal to one, no new features of SLE disease activity, and prednisone or its equivalent of less than or equal to 7.5. Additionally, there needs to be stability of immunosuppressive drugs or biologic agents.

Christina, thank you so much for framing these definitions because they are important when thinking about our targets for treatment. We're aiming at remission, and experts have provided us with a definition of remission as well as the definition for low disease activity. And the backbone of these definitions are the SLE disease activity index, the SLEDA. There is a little trepidation for practicing rheumatologists when they're thinking about the SLEDA. We try, to keep teaching and keep explaining, how the sleep day, can actually be made very easy to use and practice by doing an organ by organ, system by system approach to the evaluation of people with SLE.

We hope that integrating, disease activity instruments in EMRs is gonna make this a little easier, in the years to come.

Why is it important to work towards achieving a doris remission in lupus?

So I think that, more and more data is accumulating that clearly show, that patients that achieve remission or low disease activity have less damage accrual, less risk of flares, better quality of life, and longer survival. So all of these substantiate, remission and low disease activity as treatment targets. There's there's a magic to the word remission. So I think remission is easy to explain, and it's easy to, rally behind for both patients and doctors. Low disease activity is a little more complicated of a concept.

It's a little harder to explain. So for the most part, low disease activity is sort of a surrogate, an intermediary step before we achieve remission. And we're very fortunate that we have a lot of immunosuppressants available. We have advanced therapies, biologics. We have a wide armamentarium of drugs that if used effectively and efficiently should allow us to have a lot of patients achieve low disease activity and remission.

Do you aim for doris remission and LLDAS in your clinical practice?

So absolutely. Possibly from the first moment when I meet a new lupus patient, when I make the diagnosis, my goal is how do I take this patient from active disease, be it renal or nonrenal, be it mild, moderate to severe, and take them to remission? And it is a it is a process. It is a it is a joint effort. It requires both patients and caretakers to be involved in in defining the target and figuring out the best strategy and the best way to achieve the target.

We're not just saying, well, it'd be it would be nice to achieve remission. We're creating a little blueprint about how to get there for every patient. So I think that physicians, and providers have always thought of remission as their ultimate goal when taking care of patients with lupus or, other rheumatic diseases. But I think that now we actually have formalized what remission means. And and that the definition the DORS definition of remission is providing the guidance for what we're trying to achieve here.

So I believe that, yes, we all need to be mindful and deliberately target remission. I could not emphasize more the need to remove steroids from our treatment, our momentarium, for long term, maintenance of remission. And if we need to use them for extended periods of time, then we must think about introducing immunosuppressants or biologics. And the guidelines are pretty clear about using steroids if needed for the short for short term and just use them at the lowest dose and quickly taper and eliminate. So all of these are wisdom that has accumulated over time to allow us to achieve these treatment goals.

How successful have we been as the rheumatology community at assessing disease activity and assessing remission and implementing these treatment guidelines?

So, unfortunately, when looking at real world evidence and evaluating large databases of patients with lupus, it seems that we're falling a little short of tapering steroids in everyone. About a third of all patients with lupus in real world evidence data are not perfectly controlled or incompletely controlled. And that incomplete control is primarily due to overreliance on steroids. About over sixty percent of people in these real world evidence studies fail to meet control disease criteria based on steroid use. How good are we in implementing measurements in our everyday practice?

Probably not not as good as we'd like to be. The SLEDAY nor the PGA are fully incorporated in the electronic medical records that are used by the majority of practices in The US. So part of the task would be to allow for the incorporation of disease activity instruments in EMR so that ultimately they become easier to use. If we don't even have them in our medical records, how can we, you know, how can we ask people to actually do them? So more work needs to be done in implementing, sleep aid and PGAs into our clinical practices, and more work needs to be done in tapering people off steroids.

Interestingly, I have SLEDA incorporated in my assessments of patients with lupus, but I practice in an academic practice.

Of note, the ULAR treatment recommendations and the recently released ACR summary of guidelines focuses on the early introduction to immunosuppressive medications and biologics, as well as the reduction of glucocorticoids to less than or equal to five, and to target remission. Can you talk a little bit more about that for me?

So glucocorticoids are, you know, our best friend and our worst enemy, both as, lupus physicians, but also to our patients. They're quick. People feel better right away. So, it's very easy to be complacent and say, well, you know, the dose is a little higher, but it will be it should be okay. It isn't okay.

Damage accumulates every extra day on higher doses of steroids is a day when there's a risk for steroid induced diabetes, osteoporosis, metabolic complications, cardiovascular complications. So I think that we're understanding more and more that there's a window of opportunity to prevent damage accrual for people with lupus and that relies heavily on early introduction of immunosuppressants and advanced therapies. We very clearly recognize the need for early introduction of immunosuppressants and triple therapy for lupus nephritis, yet were a little less precise in that recommendation for the treatment of nonrenal lupus. More and more data suggests that the early introduction of immunosuppressants, of advanced therapies, of biologics provide the best opportunity to achieve remission quickly and effectively, decrease damage accumulation. Within that first year after diagnosis is the time when the risk of damage is highest, and that is most likely related to the fact that we're we're reluctant to introduce advanced therapies very quickly.

I think that early introduction, maybe we need to think of less of a sequential use of medication, but more of a front load, do more heavy treatment early on so that we can start withdrawing immunosuppression and therapies further down the line. Because ultimately, our goal here is to treat early to prevent damage because damage begets damage, and damage is associated with high risk of mortality. So the more we're able to to convey the urgency to treat early, it is likely that our patients are gonna live longer and without comorbidities and without damage. Christina, I've been speaking, about, you know, my approach and my thoughts about the early introduction of biologics and how to best provide. Guidance on achievement of remission.

But what are your thoughts and how do you do this in your own practice? You have a large practice of lupus patients as well.

So I am usually assessing patients and trying to determine what part of their disease is the worst, most active, if there's any organ threatening disease happening. And that organ threatening disease is often the thing that will drive the treatment decisions. There's a shared decision making with patients, and there's also various aspects that we do not tend to have control over. But I do wanna highlight some things like if a patient is not taking their medications for various reasons, whether it is it's giving them a side effect or cost or some other reason. So these also affect how we make our decisions for treatment.

It is important to take stock of where we're at as far as their regimen and their disease activity and discuss the importance of steroid sparing therapies and introduction of immunosuppressants and biologics.

You're making really important points here. You're making the point of shared decision making and partnering with a patient to, decide on the best treatment and what works best for each individual patient. You're highlighting barriers to to achieving remission and disease control that we need to keep in mind when we're establishing these targets. Truly important to think about the care of people with lupus as a team effort. It is the the medical team.

It is the patient, sometimes their families. Nonadherence is possibly one of the biggest reasons for treatment failures and making sure that the patients are on the same page with us by involving every relevant party in the discussion is critical.

Do you have any advice for rheumatologists regarding integrating disease activity measures into their clinical practice?

So we train the fellows. We train the the next generation of rheumatologists to think in sleep a. Think about, sort of organ system involvement like you would for any medical patients. Lupus as a systemic disease, we need to think about, you know, every system that can be involved. Once you do that, putting together the sleep a becomes easier.

So we're not looking at a very complex, activity instrument. So I I would urge everyone to look at the slidae and think about the slidae as a friend, not as a foe. Measurement is the key to fully integrating targets in our practices. I've been doing sleet day on every patient all the time. Also, minimizing steroids.

Let's figure out if you're able to taper, with the current medication regimen, or do we need to introduce additional immunosuppressants or advanced therapies. So every visit should should prompt you to think about tapering steroids and measuring disease activity.

I totally agree with that approach. I have fellows rotate in the clinic as well, and I try to further introduce the to them to improve their familiarity with the disease activity assessment. It is not integrated into our EMR at this time, but I do give scores on all of the patients that have lupus that I see. And like you mentioned, there's only a few things on there that we typically end up scoring, at least from the clinical side. So making it less tedious, less scary to them by just familiarizing them with it, and being able to zone in on the parts that we usually end up scoring, I think that's an important lesson in training the future rheumatologists in our communities.

We've talked about a lot of important information today, specifically looking at remission and lupus, and trying to treat patients with the goal of achieving remission, as well as achieving cessation and tapering of glucocorticoids as quickly as possible. We also discussed some of the measurements that are used for disease activity and for remission so that we can actually objectively score these things so we can track them better in our clinics.

So I think that we've made the point that remission is the goal. And and maybe we need to start thinking about remission from the first day we meet a lupus patient. I think that that first visit introducing the concept of remission, of steroid free remission, is possibly our best opportunity to create the therapeutic bond that will allow us to achieve remission and minimize steroid use. There probably is a window of opportunity when we can achieve quickly and effectively these low disease activity and remission targets. So think about maybe introducing things earlier so that the ultimate outcomes are better.

There's no time that the patient continues to have disease activity that is safe. Every moment of increased disease activity is time when damage accumulates. The way to achieve rapid disease control, the way to achieve remission, and the the ultimate target for treatment in people with lupus, and the way to achieve decreased steroid exposure is by introducing biologics. So I think that the more we deliberately think about these as our goals of treatment, the more we're gonna be able to achieve them. It has been, a wonderful time thinking about remission with you, Christina, and and sharing our thoughts and our experiences around achieving remission and how to get patients to this treatment goal and also how to implement the measurement instruments in our everyday practices.

We're grateful for your time, and we're grateful for this opportunity.

Thank you so much. I would like to thank our audience for listening.