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Guide Interpretation of the Asia-Pacific Lupus Erythematosus Guide, these 26 key points have been drawn!

 Last Update: 2021-11-02
 Source: Internet
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In 2021, the Asia Pacific Association of Rheumatology (APLAR) released the latest consensus on the diagnosis and treatment of systemic lupus erythematosus in the Asia-Pacific region on the Lancet
.

Systemic lupus erythematosus has a high incidence in the Asia-Pacific region and has its own characteristics.

In 2021, the Asia Pacific Association of Rheumatology (APLAR) released the latest consensus on the diagnosis and treatment of systemic lupus erythematosus in the Asia-Pacific region on the Lancet

The guideline was jointly developed by 29 experts and scholars and 3 SLE patients to develop 34 expert consensus

01 General

01 General Rules 01 General Rules

1.
The treatment of SLE should aim at disease remission
.

When the goal of remission cannot be achieved, the activity state of the disease should be reduced as much as possible

1, 1, The treatment of SLE should aim at disease remission

2, 2, It is recommended that all SLE patients (except for contraindications) routinely use hydroxychloroquine, and the maximum dose of maintenance therapy should not exceed 5 mg/kg

In addition to its immunomodulatory properties, hydroxychloroquine also has antithrombotic, lipid-lowering and blood sugar-lowering effects

For some high-risk patients, such as those with renal insufficiency, those who have taken higher doses of hydroxychloroquine daily, or those who have been taking the drug for 10 years or longer, regular visits to the ophthalmologist should be made for regular evaluation of retinopathy

3, 3.

The risk of stroke and myocardial infarction in SLE patients is increased by 2-3 times, and the risk of osteoporotic fracture is 2 times higher.

4, 4, in view of the adverse effects of treatment, immunotherapy should not be given or adjusted for patients who are only serologically active

02Prevent infection complications

02 Prevention of infection complications 02 Prevention of infection complications

A meta-analysis showed that kidney disease, infectious and thrombotic complications are the main causes of death in SLE patients
.

The prevalence and severity of lupus nephritis (LN) in Asia is higher than that in Caucasians

A meta-analysis showed that kidney disease, infectious and thrombotic complications are the main causes of death in SLE patients

5, 5.
Active hepatitis B and C should be screened and treated before immunosuppressive treatment
.

For patients receiving B cell depletion therapy or enhanced immunosuppression, occult hepatitis B screening (anti-hepatitis B core antigen and hepatitis B virus-DNA IgG antibody) and pre-treatment should be considered
.

Hepatitis B infection in SLE is recommended to be treated for hepatitis B infection before immunosuppressive therapy.
For occult hepatitis B screening (IgG-HBc and HBV-DNA) positive antiviral therapy should be considered to reduce hepatitis B reactivation
.
Prednisone treatment of 5 mg or more per day is identified as a risk factor for hepatitis B reactivation
.

6.
Tuberculosis: Active tuberculosis should be excluded before immunosuppression
.
Routine screening and treatment of latent tuberculosis are not recommended
.

6, 6, Tuberculosis: Active tuberculosis should be excluded before immunosuppression
.
Routine screening and treatment of latent tuberculosis are not recommended
.

The prevention method is first to identify the reactivation of tuberculosis.
Active tuberculosis should be treated first.
Routine screening and treatment of latent tuberculosis are not recommended
.

7.
High-risk patients can consider preventing spore pneumonia during immunosuppression
.

7,7, High-risk patients can consider preventing spore pneumonia during immunosuppression
.

In the PJP epidemiology of SLE, PCR molecular diagnosis of opportunistic fungal infection is more accurate and sensitive.
The incidence of PJP in Asian population is 0.
2-1.
9% higher than that in the United States
.
The mortality rate is 60% higher
.
All patients have lymphopenia and low CD4+ cell counts.
Caspofungin is one of the new antifungal drugs echinocandin.
It is effective for PJP and has no mortality or serious side effects
.
Trimethoprim/sulfamethoxazole (TMP/SMX) is still the first-line drug for the prevention and treatment of PJP
.

8.
It is recommended to comply with the prevention and control measures (for example, maintaining physical distance, personal hygiene, and wearing masks) specified in the national guidelines during the virus epidemic (including COVID-19 )
.
The immunosuppressive drugs should not be discontinued except in active infections where individualized decisions will be made after discussions with infectious disease experts
.

8, 8.
It is recommended to comply with the prevention and control measures (for example, keeping physical distance, personal hygiene, and wearing masks) specified in the national guidelines during the epidemic period (including COVID-19 )
.
The immunosuppressive drugs should not be discontinued except in active infections where individualized decisions will be made after discussions with infectious disease experts
.

Patients with SLE vaccination show low immunogenicity and seroprotection.
Experts worry about the effectiveness and safety of vaccination (adverse events and disease outbreaks)
.
In the influenza vaccination, it is usually safe and effective.
It is recommended to use herpes zoster (HZ), human papilloma virus (HPV), streptococcus pneumoniae and other vaccinations in stable patients.
Subunit vaccines are safe, and live vaccines should be used with caution
.
The vaccination method is gradually strengthened, that is, the start-up and strengthening strategy, and the interval between the two is at least 8 weeks
.

9.
It is recommended to vaccinate seasonal influenza, pneumococcal, human papillomavirus and herpes zoster during the quiescent period of the disease

9, 9, It is recommended to vaccinate seasonal influenza, pneumococcal, human papillomavirus and herpes zoster during the quiescent period of the disease

03 Treatment of main organ manifestations of SLE: lupus nephritis

03 Treatment of main organ manifestations of SLE: lupus nephritis 03 Treatment of main organ manifestations of SLE: lupus nephritis

Compared with white patients, Asian patients with SLE have a higher incidence of kidney disease
.

10.
In the absence of contraindications, renal biopsy should be performed before immunosuppressive treatment of active lupus nephritis
.

10, 10, in the absence of contraindications, renal biopsy should be performed before immunosuppressive therapy for active lupus nephritis
.

Because clinical symptoms and proteinuria may not necessarily be related to histological severity
.
Due to the lack of validated specific biomarkers for the diagnosis and monitoring of lupus nephritis, kidney biopsy is the gold standard for distinguishing between non-SLE-related causes and SLE-related nephropathy
.

11.
The first-line treatment for active lupus nephritis is mycophenolate mofetil or intravenous pulsed cyclophosphamide (standard dose), combined with medium-dose glucocorticoids
.
Second-line program : low-dose intravenous injection of cyclophosphamide or tacrolimus, combined with medium-dose glucocorticoids
.

11, 11.
The first-line treatment for active lupus nephritis is mycophenolate mofetil or intravenous pulsed cyclophosphamide (standard dose), combined with medium-dose glucocorticoids
.
First-line treatment plan Second-line plan Second-line plan : low-dose intravenous injection of cyclophosphamide or tacrolimus, combined with medium-dose glucocorticoids
.

Tacrolimus and other calcineurin inhibitors (for example, cyclosporin A) reduce proteinuria by stabilizing the actin cytoskeleton and inhibiting podocyte apoptosis
.
A meta-analysis of five small controlled trials from Asia showed that tacrolimus was superior to intravenous pulsed cyclophosphamide in the induction treatment of lupus nephritis, and another RCT showed that tacrolimus induced a complete renal response at 24 weeks Mycophenolate mofetil

Those that do not respond well to the standard regimen can be mycophenolate mofetil/tacrolimus combination or rituximab
.

A large RCT for Chinese patients with lupus nephritis showed that the combination of low-dose mycophenolate mofetil (1 g per day) and tacrolimus (4 mg per day) is superior to intravenous pulsed cyclophosphamide (0.
5- 1·0 g/m 2)
.

12.
The dosage of mycophenolate mofetil should be adjusted according to body weight
.
The initial dosage recommendation for Asian patients is 2 grams per day
.

12, 12.
The dosage of mycophenolate mofetil should be adjusted according to body weight
.
The initial dosage recommendation for Asian patients is 2 grams per day
.

The combination of mycophenolate mofetil and tacrolimus has also been shown to be effective in patients with refractory lupus nephritis
.
In view of the increased risk of infection and the lack of long-term safety and efficacy data, only the combination of mycophenolate mofetil and tacrolimus is recommended for patients with refractory lupus nephritis
.

13.
Mycophenolate mofetil or azathioprine can be considered as a maintenance immunosuppressant
.

13, 13, Mycophenolate mofetil or azathioprine can be considered as a maintenance immunosuppressant
.

If mycophenolate mofetil has been used for induction therapy, mycophenolate mofetil is the first choice
.
When mycophenolate mofetil and azathioprine are contraindicated or intolerant, low-dose calcineurin inhibitors can be used
.

14.
To prevent attacks, maintenance treatment of lupus nephritis should be continued for at least 5 years
.

14, 14, In order to prevent attacks, maintenance treatment of lupus nephritis should be continued for at least 5 years
.

A long-term cohort study of Chinese patients with lupus nephritis undergoing mycophenolate mofetil or tacrolimus induction and azathioprine maintenance showed that through the analysis of subject operation characteristics, maintenance therapy less than 62.
5 months is the most effective Predict kidney recurrence
.

Treatment of major organ manifestations of SLE: neuropsychiatric SLE and antiphospholipid syndrome

04 Treatment of major organ manifestations of SLE: neuropsychiatric SLE and antiphospholipid syndrome

04 Treatment of major organ manifestations of SLE: neuropsychiatric SLE and antiphospholipid syndrome 04 Treatment of major organ manifestations of SLE: neuropsychiatric SLE and antiphospholipid syndrome

15.
A combination of medium and high doses of glucocorticoids (including pulsed methylprednisolone) and cyclophosphamide is the first-line treatment for inflammatory severe neuropsychiatric SLE manifestations
.

15, 15.
The combination of medium and high doses of glucocorticoids (including pulsed methylprednisolone) and cyclophosphamide is the first-line treatment for inflammatory severe neuropsychiatric SLE manifestations
.

Including but not limited to psychosis, acute confusional state, myelitis, cranial and peripheral neuropathy, and aseptic meningitis
.

Neuropsychiatric diseases may require higher doses of glucocorticoids, including additional intravenous methylprednisolone, and moderate doses of glucocorticoids can be used for patients with less severe neuropsychiatric diseases
.

16.
For refractory neuropsychiatric SLE manifestations caused by inflammation, rituximab can be considered for treatment
.

16, 16, For refractory neuropsychiatric SLE manifestations caused by inflammation, rituximab can be considered for treatment
.

17.
For neuropsychiatric lupus erythematosus that is thromboembolized by antiphospholipid antibodies, anticoagulation therapy is required
.
Vitamin K antagonists are superior to direct-acting oral anticoagulants
.

18.
Low-dose aspirin (75-100mg/day) is used for primary prevention of thromboembolic events in patients at high risk of antiphospholipid antibodies, and whether there are other risk factors for atherosclerosis can be considered
.

05 Treatment of the main organ manifestations of SLE: other organ manifestations of SLE

19.
For severe and life-threatening SLE manifestations (eg, hematology, cardiopulmonary, gastrointestinal tract), a combination of medium to high-dose glucocorticoids (including intravenous pulsed methylprednisolone) and cyclophosphamide should be considered
.

20.
Thrombotic thrombocytopenic purpura, pulmonary hemorrhage and some hematological manifestations, such as hemophagocytosis, may consider plasma exchange
.

20, 20, thrombotic thrombocytopenic purpura, pulmonary hemorrhage and some hematological manifestations such as hemophagocytosis, plasma exchange may be considered
.

21.
Intravenous immunoglobulin G may be considered for refractory SLE, especially when hematological manifestations or other immunosuppressive regimens are contraindicated
.

21, 21.
Intravenous immunoglobulin G may be considered for refractory SLE, especially when hematological manifestations or other immunosuppressive regimens are contraindicated
.

22.
Methotrexate can be considered for persistent skin or joint manifestations
.

22, 22.
Methotrexate can be considered for persistent skin or joint manifestations
.

23.
For the performance of active SLE that is refractory to standard therapies, belimumab may be considered
.

23, 23.
For active SLE manifestations that are refractory to standard therapies, belimumab may be considered
.

24.
Options for maintenance therapy include azathioprine, mycophenolate mofetil, and calcineurin inhibitors
.

24, 24, maintenance treatment options include azathioprine, mycophenolate mofetil, and calcineurin inhibitors
.

25.
Biosimilars and generic drugs (for example, rituximab, mycophenolate mofetil, or tacrolimus) are acceptable alternatives for the treatment of SLE
.

25, 25.
Biosimilars and generic drugs (for example, rituximab, mycophenolate mofetil, or tacrolimus) are acceptable alternatives for the treatment of SLE
.

26.
It is recommended to measure the bone mineral density of patients within 6 months after starting glucocorticoids, and repeat the monitoring of bone mineral density within 1-3 years according to the risk of fracture
.

26, 26.
It is recommended to measure the bone mineral density of patients within 6 months after starting glucocorticoids, and repeat the monitoring of bone mineral density within 1-3 years according to the risk of fracture
.

For patients with moderate to high fracture risk calculated according to the fracture risk assessment tool formula and adjusted glucocorticoid dose, oral or intravenous bisphosphonate, denosumab or teriparatide is recommended
.

06 summary

06 summary 06 summary

The guideline is composed of 34 statements.
This article focuses on summarizing 25 of them.
There are still many contents worthy of further discussion in this statement, such as the status of belimumab in the treatment of LN, the vaccination of new crown vaccine, cardiovascular and Osteoporosis and other risk factors and complications such as screening and treatment
.

This guideline does not include content on pregnancy, assisted reproduction, diagnosis and treatment of special populations, etc.
, and more evidence may be needed to formulate a statement in the future
.

However, the writing of this guideline is very characteristic of the Asia-Pacific region.
It is hoped that the overall diagnosis and treatment of SLE in the Asia-Pacific region can be improved, and ultimately the long-term prognosis of SLE patients can be improved
.

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