Lupus Year in Review: 2022

In the final installment of our Year in Review series, Rheumatology Network interviewed Alfredo Aguirre, MD, to discuss the latest data regarding lupus this year at the American College of Rheumatology (ACR) Convergence 2022, trends in lupus management, and the importance of remission in lupus and its association with improved quality of life and improved outcomes in this patient population. Aguirre is Assistant Clinical Professor at the University of California, San Francisco.

Alfredo Aguirre, MD

Rheumatology Network: What studies or new data related to lupus stand out to you most prominently in 2022?

Alfredo Aguirre, MD: I think one theme that came out in lupus this year was safety of some of our newer agents, newly approved agents, and agents approved for new indications, like belimumab for lupus nephritis, anifrolumab for active lupus, and voclosporin for lupus nephritis. There were some data presented at the ACR Convergence, as well as publications, that were overall reassuring for safety and durability of response.

Another theme was the importance of remission in lupus. Data has been coming out about remission and its association with improved quality of life, improved mortality in lupus, and improved outcomes, such as reduced organ damage. The concept of remission is relatively new and may be a new treatment target for us in clinical settings.

There was also an interesting presentation at the ACR this year on hydroxychloroquine and lupus flares. They studied the association between lowering a dose of hydroxychloroquine in patients and subsequent flares. It was a complicated study design, but basically what I got out of that study is that if I inherited a patient, for instance, who was on a high dose of hydroxychloroquine and who is above the threshold record that's recommended now by the new guidelines, I would not reduce their dose unless they have stable disease as to not increase their risk of theoretical flare. There needs to be more studies to confirm this risk, but it was a well-designed study.

RN: Have you noticed any overarching trends in lupus management and treatment over the past year?

AA: The major thing that has changed over the past few years is a move to multi-target therapy in lupus nephritis, which is the idea of prescribing multiple immunosuppressants instead of 1 or 2 on diagnosis. I think the field is still struggling about when to do that and how to sequence medicines. We’re all still kind of figuring out what to do about that problem. It's not unique to this year, but it is a trend that is relatively new that we have this option of, in the spirit of improving outcomes for patients with lupus, we can add, in many cases, a second steroid sparing agent to a regimen and many times it's very safe. Like I said, we've shown a lot the safety of these of these agents, for instance, like belimumab for lupus nephritis.

RN: What are the most pressing issues and lupus that you hope to see addressed in 2023?

AA: I think it's troubling that the remission rates for lupus nephritis are relatively low and relapse rates remain relatively high. We still don't understand who would benefit from what therapy and we don't have a good idea of precision medicine in lupus. Another pressing need is reducing steroid exposure.