Developments in the treatment of SLE and Covid-19 considerations

Irish Society for Rheumatology Spring Meeting, Virtual, 13 May 2021

Prof Michelle Petri, Professor Division of Rheumatology at Johns Hopkins University, US, closed the ISR Spring Meeting with her presentation providing an overview of modern lupus treatment. Prof Petri is the Director of the Hopkins Lupus Cohort, a longitudinal cohort of morbidity and mortality in systemic lupus erythematosu (SLE) patients and Co-Director of the Hopkins Lupus Pregnancy Centre.

Asserting that “we cannot continue to rely on corticosteroids” in the treatment of lupus given their negative impact, Prof Petri referenced a cohort study by the Toronto Lupus Group, which showed that after 10 years from the date of diagnosis with lupus, 80 per cent of patients in the cohort suffered from permanent organ damage as a result of steroids.

Prof Petri strongly advocates for the use of hydroxychloroquine as a background therapy in all SLE patients. Although it has been found to increase the incidence of retinopathy, the use of OCT ocular imaging can be used to detect this at an early stage, avoiding any loss of visual acuity.

The current use of immunosuppressant drugs in the treatment of lupus is predominantly organ-based, with methotrexate, mycophenolate, leflunomide, and azathioprine noted for different organs. Prof Petri raised some interesting new developments of note. Anifrolumab, which is awaiting US FDA approval, showed a positive BILAG-Based Composite Lupus Assessment response after four weeks, a positive SRI (4) response after eight weeks and a clear benefit for skin with Cutaneous Lupus Erythematosus Disease Area and Severity Index activity increasing at four weeks. Prof Petri observed this in her own patients and noted durable results for skin.

Regarding the ongoing pandemic, Prof Petri also addressed current considerations in light of Covid-19. She advised that prednisone needs to be limited, something she would advise in any case due to the increased risk of cardiovascular events it poses. However, rituximab also needs to be limited, where possible, to avoid any increased risk to the patient. In relation to vaccination, there were fears that the mRNA vaccines may cause lupus flares, but this has not materialised in Prof Petri’s experience.

Further, it was thought that renal transplant literature suggests that patients being administered mycophenolate may not have the expected antibody response to the Covid-19 vaccines. To attempt to address this in her own patients, Prof Petri has held off on the use of the major immunosuppressive medications for one week post vaccination, although success cannot be confirmed at this point.