More suitable for Asian crowd!

*Only for medical professionals to read for reference, the best for you is the best! Systemic lupus erythematosus (SLE), as an autoimmune disease that is prevalent worldwide, is particularly prevalent in Asian populations, with an incidence rate of 0.
9-8.
4 cases per 100,000 people, and the prevalence rate is as high as There are 3.
7-127 cases per 100,000 people, the prevalence is second only to Africans.
It is initially estimated that there are 1.
2 million SLE patients in China
.

In addition, the burden of SLE patients in Asia is more serious, the disease is more active, more renal complications, and the morbidity and mortality are still increasing [1]
.

In view of the unique characteristics of SLE among Asian populations, the Asia-Pacific Rheumatism Alliance (APLAR) has organized several discussions and revisions by experts in the Asia-Pacific region for more than 2 years, and finally published in 2021 SLE management guidelines that are more suitable for people in the Asia-Pacific region.
At the APLAR annual meeting, Professor Mo Zhichao from Tuen Mun Hospital in Hong Kong elaborated on the consensus on the guidelines
.

The arrow is on the bow, and I have to issue: it is necessary to formulate a SLE management guide that is more suitable for the Asia-Pacific region.
As early as 2012, some scholars pointed out that the incidence of nephritis in SLE patients in Asia is higher than that of Caucasians, reaching 21%-82%[2]
.

At the same time, according to the results of the Aspreva Lupus Management Study (ALMS), Asians are less tolerant to the conventional anti-rheumatic drugs mycophenolate mofetil (3g/day) or biological agents such as ocrelizumab, and mycophenolate Compared with cyclophosphamide, acid esters do not reduce the risk of infection
.

In terms of neuropsychiatric performance, Asians are more likely to have psychosis and cognitive impairment, while Caucasians are more likely to have symptoms such as encephalopathy, cerebrovascular events, and delirium
.

In addition, the medical insurance resources available to people in the Asia-Pacific region are relatively small, and the diagnosis of SLE is often delayed
.

The most important thing is that Asians are more concerned about drug toxicity, which has also led to poor compliance with drug treatment[3].
.
.
Under the combination of various problems, the development of a SLE management guide that is more applicable to the actual situation in the Asia-Pacific region is the arrow.
Up
.

The development of this SLE management guideline was initiated by 13 core experts, and finally 34 statements were put forward to guide the clinical practice of SLE in the Asia-Pacific region
.

Figure 1: Comparison of SLE-related guidelines in Asia and Europe [4] 5+4: The basic principles are at hand, and the SLE management guide is half-knowledgeable.
Before you start learning APLAR's SLE management guide, you must memorize these key points
.

Four principles of disease recognition: SLE patients need to be evaluated by a multidisciplinary team (lupus experts, nursing experts, and other experts involved in health insurance), and both doctors and patients make joint decisions and make management plans
.

Individualized SLE treatment plans should be customized on the basis of disease severity, complications, and patient compliance
.

Early diagnosis of SLE and timely consultation with lupus experts can significantly improve the outcome of the disease
.

The overall goal of SLE treatment is to reduce organ damage, ensure long-term survival of patients, and improve the quality of life of patients
.

Five principles of disease treatment: SLE classification and disease activity assessment should be performed using well-validated standards.
The latter is especially suitable for practice with the goal of prescription or research
.

The treatment goal of SLE is disease remission.
When disease remission cannot be met, the treatment goal should be the minimum disease activity
.

Unless the drug is resistant or intolerant, hydroxychloroquine (HCQ) is recommended as the routine medication for all SLE patients, and the maintenance dose should not exceed 5 mg/kg/day
.

The cardiovascular system and skeletal system should be evaluated regularly, and the use of drugs or non-drug means to improve the health of these two aspects should be recommended
.

Due to the adverse reactions of immunosuppressive agents, the drug should not be stopped or adjusted based on serological evidence alone
.

Basic treatment of SLE: Hydroxychloroquine is routinely used, and glucocorticoids should pay attention to HCQ and glucocorticoids (GC) as frequent visitors of a variety of rheumatoid immunological treatment strategies.
Naturally, they will not miss the basic treatment of SLE
.

Among them, APLAR believes that HCQ is for the treatment of SLE just like methotrexate is for the treatment of rheumatoid arthritis.
It is the best choice for the basic medicine for the treatment of SLE.
Its clinical benefits are reflected in disease remission, reduction of recurrence, and good medicine.
Economic aspects
.

The use of GC must be more wise.
In recent years, many studies have confirmed that the dose of GC is not the smallest but only less.
Therefore, in clinical practice, the use of GC should be reduced and stopped as appropriate to seek the greatest benefit in terms of efficacy and side effects [5]
.

For specific GC reduction and stop usage, please refer to the guidelines recommended by the European Union Against Rheumatism (EULAR) 2019, which will not be repeated here
.

Prevention of infectious complications: Except before treatment, screening during treatment, vaccination, one cannot be less than the inevitable use of immunosuppressive agents in SLE treatment, so prevention of infectious complications is particularly important
.

APLAR does not routinely recommend screening for tuberculosis during SLE treatment, so the possibility of tuberculosis in patients must be ruled out before starting immunosuppressant use
.

For hepatitis B and C, APLAR also recommends screening before the start of immunosuppressive agents, especially for SLE patients who often use immune agents or B cell depletion therapy
.

In addition, the prevention of Pneumocystis jiroveci pneumonia during immunosuppressive treatment is also necessary.
Patients suffering from pneumonia during the treatment should be regarded as high-risk patients with Pneumocystis jiroveci pneumonia
.

For other epidemic infectious diseases including new coronary pneumonia, APLAR recommends that SLE patients take measures such as keeping distance, wearing masks, and enhancing personal hygiene, and when it is unnecessary and there is no specialist infection doctor to make decisions, active infected patients are in principle Do not stop immunosuppressive therapy
.

It is worth noting that in terms of influenza, pneumococcal, human papilloma virus and shingles vaccine preventive measures, APLAR recommends the lowest dose of immunosuppressive therapy during the resting period of the disease before vaccination
.

Asian SLE complications focus: Lupus nephritis management plan exclusively for Asians As mentioned above, the proportion of nephropathy complications in Asian SLE population remains high, and the guidelines also pay special attention to the management of lupus nephritis (LN)
.

APLAR pointed out that unless the patient refuses, a kidney biopsy should be taken before immunosuppressive therapy for active LN
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For active LN graded 3-5 by the International Society of Nephrology and the Society of Renal Pathology (ISN/RPS), the first-line treatment for inducing remission recommends the use of mycophenolate mofetil or intravenous cyclophosphamide combined with medium-dose GC
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The second-line treatment regimen recommends lower-dose intravenous cyclophosphamide or tacrolimus combined with medium-dose GC
.

The recommended starting dose of mycophenolate mofetil for Asian population is 2g/day, and the dose should be adjusted according to the weight of the patient
.

If patients with active LN respond poorly to treatment, a combination of mycophenolate mofetil and tacrolimus or rituximab alone is recommended as the first-line treatment
.

The maintenance treatment of LN recommends the use of mycophenolate mofetil or azathioprine as an immunosuppressive treatment option.
If mycophenolate mofetil has been used in the remission induction phase, mycophenolate mofetil is preferred as a maintenance option
.

If mycophenolate mofetil or azathioprine is intolerant or resistant, then low-dose calcineurin inhibitors can be used as treatment options
.

In order to prevent disease recurrence, the course of maintenance treatment of LN should last at least 5 years
.

Other complications: neuropsychiatric lupus and antiphospholipid syndrome management programs, medium to high-dose GC (including intravenous methylprednisolone) and cyclophosphamide as the first-line treatment of inflammatory-derived severe neuropsychiatric lupus, including but not limited to psychosis, acute psychiatric disorders, myelitis, cranial nerve and peripheral neuropathy, aseptic meningitis
.

Rituximab can be used for refractory neuropsychiatric lupus caused by inflammation
.

Symptomatic treatment is very important for neuropsychiatric symptoms such as encephalopathy, depression, and cognitive impairment
.

For thrombotic neuropsychiatric lupus patients with positive antiphospholipid antibodies, anticoagulation therapy should be used
.

For patients with high-risk thrombotic antiphospholipid syndrome with positive antiphospholipid antibodies, vitamin K antagonists are superior to direct-acting oral anticoagulants
.

Regardless of whether it is associated with other risk factors for atherosclerosis, low-dose aspirin (75-100mg/day) can be used as a preventive medication for thrombotic events in high-risk patients with positive antiphospholipid antibodies
.

Multi-system involvement: other organ damage management options.
When SLE patients have other organ damage, medium to high doses of GC (including intravenous methylprednisolone) and cyclophosphamide can be used as treatment options for severe or life-threatening conditions, such as blood, cardiovascular And the digestive tract is affected
.

Plasma exchange can be used for thrombotic thrombocytopenic purpura, pulmonary hemorrhage and certain blood complications, such as hemophagocytic syndrome
.

For refractory SLE, intravenous immunoglobulin G can be considered, especially when complicated by hematological diseases or other immunosuppressive agents are not available
.

Methotrexate can be used for patients with persistent skin or joint symptoms
.

Biologics selection: Beilimumab in the treatment of SLE and LN According to a number of randomized controlled trials in China, Japan and South Korea [6], Beilimumab can significantly improve the disease activity of SLE patients and reduce the use of GC.
Will not cause additional security issues
.

Under the premise of failure of standard treatment, intravenous belimumab has been approved for autoantibody-positive SLE patients over 5 years old and adults
.

The subcutaneous injection of belimumab has also been approved for adult patients under the same conditions
.

APLAR’s SLE management guideline formulation members affirmed the economics of belimumab and believes that it can be used as a supplementary treatment for patients with SLE or LN that does not respond well to standard treatment.
At present, relevant clinical trials have been published, and the next update The mid-session will continue to discuss the possibility of belyumumab entering the first-line treatment program
.

Other treatment options: Maintenance therapy can choose hydroxychloroquine/mycophenolate mofetil/tacrolimus
.

In addition to these therapeutic options, some of the biological agent and the like may also be used as generic chemical drug treatment of SLE, such as rituximab similar biological drug, HCQ / mycophenolate mofetil / tacrolimus generic chemical like
.

Figure 3.
The diagnosis and treatment flow chart of APLAR SLE management guidelines [4] Summary: APLAR SLE management guidelines are composed of 34 statements.
Later APLAR will continue to update this guideline belonging to the Asia-Pacific region based on newly discovered evidence
.

In this statement, there are still content worthy of in-depth discussion, including the status of belyumumab in the treatment of LN, new coronavirus vaccination, pulmonary hypertension and interstitial lung disease screening, and thrombopoietin receptor agonist treatment Refractory immune thrombocytopenia, cardiovascular and osteoporosis risk factors and complication screening, etc.
, and issues related to pregnancy, assisted reproduction and obstetric antiphospholipid syndrome require additional expert investigation meetings to discuss
.

Experts comment that SLE is a classic autoimmune disease with strong clinical heterogeneity and high requirements for individualized diagnosis and treatment
.

In the Asia-Pacific region, especially in China, the prevalence of SLE ranks second in the world, about 70-100 cases per 100,000 people, and more than 1 million people are affected; and the proportion of LN is as high as 47.
4%, and there is also neuropsychiatric Lupus, pulmonary hypertension and other organs are affected, and the condition is more serious than SLE of other races.
Therefore, it is urgent to develop SLE diagnosis and treatment guidelines that meet the characteristics of the Asia-Pacific region
.

The preparation of the management guidelines is guided by clinical issues, based on evidence-based medicine, in line with international concepts, combined with the characteristics of SLE patients in the Asia-Pacific region, and provides rheumatology immunologists with standardized diagnosis and treatment of SLE in terms of diagnosis, disease evaluation and treatment.
The suggestion is to improve the overall diagnosis and treatment of SLE by rheumatology and immunology in the Asia-Pacific region, promote early diagnosis and achieve standard treatment, and ultimately improve the long-term prognosis of SLE patients
.

Expert profile Associate Professor Zhao Jiuliang, associate professor, master tutor, and assistant director of the Department of Rheumatology and Immunology of Peking Union Medical College Hospital.
Mainly engaged in basic and clinical research on rheumatism and immune diseases such as systemic lupus erythematosus, antiphospholipid syndrome, connective tissue disease-related pulmonary hypertension, etc.
National "Eleventh Five-Year", "Twelfth Five-Year", "Thirteenth Five-Year" science and technology support programs related to systemic lupus erythematosus have spoken on behalf of the team 13 times in national academic conferences, 9 times in international conferences, and participated in the publication of SCI More than 90 articles, including the first author and corresponding author, 24 SCI articles won the International Youth Award of the Japanese Academy of Rheumatology, the East Asian Rheumatology Society Youth Award, the International Lupus Conference Travel Award, the Chinese Medical Association Rheumatology Society Outstanding Paper Award, Medical Journal "Golden Pen Award", 2020 China Medical Journal "Top Ten Young Investigators Award", and the 2nd Union Outstanding Youth Award.
Currently serving as Deputy Chairman of the Youth Committee of the Chinese Medical Association Rheumatology Branch, Asia Pacific Rheumatology Alliance (APLAR) ) Vice Chairman of the Youth Committee, Vice Chairman of the Youth Committee of the Chinese Medical Doctor Association Rheumatology and Immunology Branch, Member and Secretary of the Beijing Society of Rheumatology, Deputy Editor-in-Chief of "Front Med (Lausanne)" (IF 5.
091), "Peking Union Medical College", "Chinese Journal of Clinical Immunity and Allergy" Youth Editorial Board Reference: [1] Tanaka Y, O'Neill S, Li M, et al.
Systemic Lupus Erythematosus: Targeted literature review of the epidemiology, current treatment and disease burden in the Asia Pacific region[J].
Arthritis Care&Research,2020.
[2]Jakes RW,Bae SC,Louthrenoo W,et al.
Systematic review of the epidemiology of systemic lupus erythematosus in the Asia‐Pacific region:prevalence,incidence,clinical features,and mortality [J].
Arthritis care&research,2012,64(2):159-168.
[3]Thong KM,Chan TM.
Infectious complications in lupus nephritis treatment: a systematic review and meta-analysis[J].
Lupus,2019,28(3):334 -346.
[4]Oku K,Hamijoyo L,Kasitanon N,et al.
Prevention of infective complications in systemic lupus erythematosus:A systematic literature review for the APLAR consensus statements[J].
International Journal of Rheumatic Diseases,2021.
[5 ]Fanouriakis A,Kostopoulou M,Alunno A,et al.
2019 update of the EULAR recommendations for the management of systemic lupus erythematosus[J].
Annals of the rheumatic diseases,2019,78(6):736-745.
[6] Zhang F,Bae SC,Bass D,et al.
A pivotal phase III,randomised,placebo-controlled study of belimumab in patients with systemic lupus erythematosus located in China,Japan and South Korea[J].
Annals of the rheumatic diseases,2018 , 77(3):355-363.
Source of this article: Medical Rheumatism Channel Author of this article: Guizhi Review of this article + comments: Associate Professor Zhao Jiuliang Editor in charge of Peking Union Medical College Hospital: cassette copyright statement The original text of this article is welcome to forward to the circle of friends-End-