Treatment goal in SLE is to reduce infections, prevent thrombosis, reduce and prevent disease flare up-David D’Cruz


 Rheumatology Conference Proceedings-III

Treatment goal in SLE is to reduce infections,
prevent thrombosis, reduce and prevent
disease flare up - David D’Cruz

Careful clinical evaluation with judicious use of investigation
remains the key to correct diagnosis - Aisha Lateef

LAHORE: Prof. Kamran Hameed along with Prof. Kamran Chima from SIMS chaired the second session of the Rheumatology conference held here from April 10-12, 2015.  Prof. David D’Cruz from Guy’s Hospital London was the first speaker who talked about Difficult Lupus. SLE, he said, can be mild or severe. He referred to the ACR classification and criteria for diagnosis of SLE. Predictors of poor outcome were mentioned as female, black, infections, young age, those suffering from renal disease, disease for more than one year.  There has been a dramatic decrease in mortality. He also talked about pathogenesis and course of SLE. Flares, he said, are common, it can be mild, moderate to severe and they increase the cost to the patient because of increased hospitalization.

Speaking about diagnosis of Systemic Lupus Erythematosus (SLE), Dr. D’Cruz emphasized the importance of careful history; all systems examination should be done. SLE patients require multidisciplinary care including neurophysician and psychiatrists. In severe SLE there is neurological involvement.  Treatment goal is to reduce infections, prevent thrombosis, reduce and prevent disease flare up. Choice of treatment depends on disease severity, duration and organ involvement. Steroids should be used in an effective dosage for longer periods.  He also talked about the efficacy of anti-malarial therapy besides immunosuppressive agents such as Azathioprime.  He was of the view that one should try to minimize exposure to corticosteroids to reduce treatment related damage. There are validated tools to document disease flares in addition to the tools to measure disease activity and damage. He also talked about CVD risk, thrombosis risk and Vitamin D therapy.  Early diagnosis and management ensures improved outcome, he remarked.


Prof. Nighat Mir along with Prof. Kamran Hameed chairing one of the
scientific sessions during the Rheumatology conference held
at Lahore from April 10-12, 2015.

Dr. Aisha Lateef from National University of Singapore talked about Mimics of Lupus. SLE, she said, is considered the great mimic of other conditions.  There is a risk of over diagnosis, diagnosis is often delayed or it is missed. There are many diseases which can mimic SLE as a systemic disease or as dermatological Rheumatological or immunological mimickers.  Chronic infections and malignancies can mimic autoimmune diseases including SLE; serologies can be misleading in such scenarios. One should consider infections associated rheumatic/autoimmune syndromes when the presentation is not typical. Dr. Aisha Lateef further stated that there is a risk of over diagnosis.  She then presented a few case histories. All SLE patients, she said,  present with joint pain, rash, SICCA, GIT problems are therefore common. One should treat the patient and not the tests results. One of her patients  32 years old male presented with joint pains, rheumatic disease, HIV and many  associated  diseases. Dr. Aisha Lateef opined that one should look at the overall clinical picture. This patient had rashes and lumps in neck, LPD and Autoimmune disorders.  Lymphadenopathy is common in SLE, she added. Next patient she presented was thirty years old female who had fever for ten days. She presented with hot knots. She talked about drug induced SLE and said that many drugs are the culprits and the list of these drugs is growing. She was of the view that   careful clinical evaluation with judicious use of investigation remains the key to correct diagnosis. She also referred to disseminated TB in SLE patients. There is a high risk of infection in SLE patients and one has to be very careful.

Prof.Irshad from KEMU chaired the next session wherein Dr.David D’Cruz spoke about Rituximab in Lupus and ANCA positive vasculitis: Predictors and biomarkers of response and relapse.  SLE and ANCA associated vasculitis including granulomatosis with polyangitis, he said, are autoimmune diseases which develop due to failure of immune self-tolerance. This disease could be life and organ threatening. A variety of factors  have been  identified as  predictors of relapse in SLE like  renal disease, high disease activity, neurological disease, coetaneous vasculitis, persistently high anti-DNA antibodies and hypocomplementemia.  In ANCA associated vasculitis, factors associated with increased risks of relapse include diagnosis of GPA, ENT diseases, renal impairment and treatment withdrawal. One should achieve remission with induction therapy and then maintain that remission. He also talked about recognition of relapse, resistance of disease, prevention of damage and mortality. Prednisone 1mg/kg body weight is quite effective. He also referred to the BSR guidelines of rheumatology. Rituxivas has adverse drug reactions in 42% of patients. Relapses matter more in this condition. Rituximab, he stated, was superior to Azathioprime in remission. Rising titers always do not predict relapse.   He also talked about   systemic vasculitis and co morbidities. Rituximab, he sated, is quite effective in Lupus nephritis, SLE and GPA. His advice was that one should minimize and avoid the use of steroids, have greater focus on damage and quality of life. Treat to target approach prevents co-morbidities and infection, he added.