Bevra Hahn, Professor of Medicine at UCLA, gave a fantastic talk detailing pearls pertaining to lupus. Here were the take away findings that might change my practice:
1) Inflammatory arthritis in lupus is based on a different gene expression that is interferon-dominant and different than other forms of inflammatory arthritis.
2) Lupus arthritis can include erosions (maybe not seen on x-ray, but detected by ultrasound), tenosynovitis and synovitis.
3) Blood levels of hydroxychloroquine may be useful to at least monitor drug compliance. Some studies suggest that higher concentrations are also important in reducing flare rates.
4) While a "safe acceptable dose" of steroids remains controversial, she recommends maintenance doses of no higher than 6 mg /day. Consider a long-acting depot IM steroid to give 3-4 weeks of coverage when waiting for other drugs to take effect.
5) Other formulations of steroids are being looked at in lupus. For example, RAYOS (which is a "delayed release" formulation with a waxy outer coating and an internal prednisone dose of 1, 2 or 5 mg) provides an "early morning" delayed release of prednisone that can help manage lupus symptoms and fatigue (but it's still steroids!).
6) The cost of lupus drugs has gone up even in the 2 years since Dr. Hahn has reviewed it (commentary on the concerns of drug pricing!!!!).
7) Ischemic necrosis of the bone in lupus includes important risk factors such as high-dose glucocorticoids, early disease (first year), young (< 40 years of age), and long duration of treatment (this includes most of our patients with bad disease activity!).
8) Treatment of ischemic necrosis of the bone in the early stages remains unclear and controversial. Whether surgical decompression has a role has not been adequately studied and will depend on where you practice and who your orthopedic surgeon is (I suspect this will vary considerably per site and whether you can even get a hold of your orthopod).
9) Total hip replacements for lupus patients with more advanced stage ischemic necrosis have been successful but not without some complications (again – talk to your orthopod if you can find him or her).
10) Medical interventions for preventing femoral head collapse are unclear with conflicting data for alendronate and zoledronic acid. More studies are needed (many of our patients may already be on a bisphosphonate when they develop ischemic necrosis!).
11) FRAX is better than densitometry – so use it instead (but some extrapolation is needed as age < 40 was not evaluated and it does not include lupus!).
12) Lupus pregnancies have a 92% chance of having no adverse outcomes (fetal death, low birthweight or premature delivery) if patients do NOT have the following risk factors from the PROMISSE study:
positive lupus anticoagulant (OR 8.32, p<0.001)
current antihypertensive treatment (OR 7.05, p<0.001)
severe flare during pregnancy (OR 5.87, p<0.03)
worse physician global activity score (OR 4.02, p<0.001)
non-Hispanic white (OR 0.45, p=0.01)
low platelet count (OR 1.33, p<0.006)