6/24/2016 Outline • Diagnosis and assessment • Contraception Lupus for the Internist: • Cardiovascular disease Advances in Internal Medicine 2016 • Vaccinations and infectious complications • Advances in treatment Sarah Goglin, MD Assistant Professor of Medicine University of California, San Francisco What is SLE? Epidemiology of SLE • Autoimmune disease characterized by the production of autoantibodies • Involvement of multiple organ systems • Heterogeneous disease pattern • Characterized by flares and periods of quiescence SLE prevalence ~1/1500 Americans 1
6/24/2016 Case • 27 year old woman presents with two months of erythematous rash on Diagnosis and Assessment hands and joint pain • Labs reveal mild lymphopenia, normal CRP, and elevated ESR • ANA >1:640 speckled pattern • C3 and C4 low Choosing Wisely – ABIM/ACR 1997 ACR Classification Criteria • Malar rash • Discoid rash Mucocutaneous • Photosensitivity • Oral ulcers • Arthritis • Serositis Internal organ • Renal disorder • Neurologic disorder • Hematologic disorder: hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia • Immunologic disorder: anti-dsDNA, anti-Sm, ACL IgG/IgM Lab • Anti-nuclear antibodies Yazdany, J. Arthritis Care & Research. 2013 March; 65(3): 329–339. 2
6/24/2016 1. Malar Rash 1. Malar Rash 2. Discoid Rash 2. Discoid Rash 3
6/24/2016 3. Photosensitivity 3. Photosensitivity 4. Oral Ulcers 5. Arthritis 4
6/24/2016 6. Serositis 7. Renal Disorder 8. Neurological Disorder 9. Hematologic disorder • Hemolytic anemia • Leukopenia (<4K) • Lymphopenia (<1.5K) • Thrombocytopenia (<100K) 5
6/24/2016 10. Immunologic 11. Positive ANA • Anti-phospholipid antibody • Anti-dsDNA • Anti-Sm • (False + test for syphilis) False positive rate in healthy controls: 3% (ANA 1:320) to 30% (ANA 1:40) Case Lupus Nephritis • You refer your patient to rheumatology for a • ~30% of patients with SLE have evidence of new diagnosis of lupus based on positive ANA, nephritis at time of diagnosis • Overall, prevalence of lupus nephritis is ~50- dsDNA, hypocomplementemia, leukopenia, specific lupus rash, and arthritis 60% in first ten years after diagnosis • What other tests are critical in triaging this • Screen for renal involvement in ALL patients patient? with lupus at time of diagnosis and in follow up with urinalysis and urine protein and urine creatinine (spot is fine) Hahn, B. Arthritis Care & Research. 2012 June; 64(6): 797-808. 6
6/24/2016 Case Lupus Nephritis • Her urinalysis reveals 1+ protein, 5-10 RBCs • Indications for renal biopsy – Increasing serum Cr and spot UPCR is 0.7 g/g • Does she need further work up for these – Proteinuria ≥1.0 g per 24h – Proteinuria ≥0.5 g per 24h plus hematuria findings? – Proteinuria ≥0.5 g per 24h plus cellular casts Hahn, B. Arthritis Care & Research. 2012 June; 64(6): 797-808. Case Lupus Flare versus Infection Your patient is diagnosed with focal proliferative (class III) Lupus Flare Infection lupus nephritis and is started on Cellcept, prednisone, and hydroxychloroquine Leukopenia, thrombocytopenia Leukocytosis, thrombocytosis 6 months later, routine labs reveal a white blood cell Normothermic Fever, shaking chills count of 1.9K 57% Elevated ESR, normal CRP Elevated ESR and elevated CRP You advise her to: Decreased C3 and C4 Unchanged C3 and C4 from A. Stop Cellcept and recheck labs 30% prior in 1-2 weeks Increased dsDNA Unchanged dsDNA from prior 7% 7% B. Increase prednisone to 20 mg Specific signs of lupus activity Localizing signs of infection C. Stop hydroxychloroquine (e.g. arthritis, rash) Get blood cultures drawn Stop Cellcept and rechec... Increase prednisone to .. Stop hydroxychloroquine D. Get blood cultures drawn 7
6/24/2016 Case Side Effects of SLE Treatments • She is feeling well, with no evidence of Medication Side Effects Steroids Too numerous to list infection or lupus activity. Her dsDNA and C3 Hydroxychloroquine Retinal damage levels are unchanged and platelet count and hematocrit are normal. Methotrexate Liver damage, bone marrow suppression, infection Azathioprine Bone marrow suppression, infection Mycophenolate Bone marrow suppression, infection Cyclophosphamide Bone marrow suppression, infection Belimumab Infection, GI Case • You advise her to: A. Stop Cellcept and recheck labs in 1-2 weeks Contraception B. Increase prednisone to 20 mg C. Stop hydroxychloroquine D. Get blood cultures drawn 8
6/24/2016 Case Contraception and Lupus She returns to you for follow up and is not using • Fertility is preserved! contraception. She is sexually active with her husband. She asks you what you recommend for • Many of our patients are on teratogenic contraception. 53% medications (Cellcept, ace inhibitors, etc) You recommend: • Patients with active SLE or significant end 41% A. Nuva-ring organ damage (e.g. CKD) are at increased risk B. IUD for adverse outcomes during pregnancy • Appropriate counseling about contraceptive C. Depo Provera 3% 3% D. Need more information g D methods is critical a n n U r e o i I i r v t - o a a m v r u P r N o o p f n e i D e r o m d e e N Buyon J. Ann Intern Med. 2015;163(3):153-163. Tedeschi S. Clin Rheumatol . 2016 May 11. [Epub ahead of print] Contraception and Lupus Contraception and Lupus • Antiphospholipid antibody status – APL antibodies include lupus anticoagulant, anti- cardiolipin IgG and IgM, and anti-beta-2 glycoprotein I IgG and IgM – APL positivity is a contraindication to estrogen- containing methods, regardless of whether patient has had previous thrombosis – Progestin-only or non-hormonal methods are recommended • Effects on bone density – Concern about Depo Provera, especially in patients with chronic steroid exposure Sammaritano LR. Lupus. 2014 Oct;23(12):1242-5. 9
6/24/2016 Case • You recommend: A. Nuva-ring Cardiovascular Disease B. IUD C. Depo Provera D. Need more information Case Cardiovascular Disease and Lupus Your patient presents to the ED with chest pain radiating to the neck. EKG shows ST depressions in the inferolateral leads. Her troponin is elevated. What is the most likely cause of her cardiac ischemia? 41% A. Myocarditis B. Coronary artery vasculitis 24% 18% 18% C. Pericarditis D. Atherosclerotic coronary artery disease s s i s i . t t i t . d i i d i . l y r u r r a c a a c c o s n a r i o y v e r M y P o c r e c t i r t a o y r r e l CVD is a leading cause of mortality in patients with SLE a c n s o o r r o e h C t A 10
6/24/2016 Cardiovascular Disease and Lupus Cardiovascular Disease and Lupus • Traditional risk assessment tools • All-cause mortality has declined in SLE has underestimate risk of CVD in lupus patients declined over the past 20 years, but the risk of • Modified Framingham risk score in which item death due to CVD remains unchanged is multiplied by 2 more accurately predicts • Management of traditional modifiable risk CAD in patients with lupus factors is important, but we do not how much • This may better highlight the population to this mitigates this risk target for intensive risk factor modification; however, we don’t know if acting on this multipler risk calculation impacts outcomes Bjornal L . J Rheumatol. 2004 Apr;31(4):713-9. Urowitz . J Rheumatol. 2016 May;43(5):875-9. Fors Nieves CE. Curr Rheumatol Rep. 2016 Apr;18(4):21. Case • Your patient presents to the ED with chest pain radiating to the neck. EKG shows ST depressions Vaccinations and Infectious in the inferolateral leads. Her troponin is elevated. Complications • What is the most likely cause of her cardiac ischemia? A. Myocarditis B. Coronary artery vasculitis C. Pericarditis D. Atherosclerotic coronary artery disease 11
6/24/2016 Case Vaccinations and Lupus • Infections are a significant cause of death in • Your patient, who is on Cellcept, has read lupus patients online that vaccines may not be safe for her to • Strongly recommend annual inactivated flu get. What do you tell her? vaccine, PCV13 (Prevnar), and PPSV23 (Pneumovax) in all patients on immunosuppression, regardless of age, according to ACIP guidelines • Live vaccines should be avoided in patients on immunosuppressive medications MMWR, October 12, 2012, Vol 61, #40 Invasive Pneumococcal Disease Pneumococcus and Lupus Pneumococcal pneumonia Invasive Pneumococcal Disease (IPD) 10-40% fatality Invasive pneumococcal disease Meningitis Bacteremia Pneumonia (NPD) 6.3% 19.2 % 66.5% Shea K. Open Forum Infect Dis. 2014 March. 12
6/24/2016 New ACIP/CDC/ACP Case 2015 Guidelines Recommend 2 Vaccines You receive a message from your patient: “I’ve developed a painful rash and I’m worried it may be due to lupus.” Zoster and Lupus Zoster and Lupus Yun, H . Arthritis and Rheumatology . 2016 Mar 18. [Epub ahead of print] Murray S . PLoS One . 2016 Jan; 11(1). 13
6/24/2016 Case • Your patient asks you if you’ve heard anything about the lupus medication she has seen Advances in Treatment commercials about on TV. She thinks it starts with a “B”. Biologic Therapies in Lupus B-cell targeted therapy • Belimumab • Rituximab • Multiple other drugs in various phases of investigation Best Practice & Research Clinical Rheumatology, 29 (6), 2015, 794–809 14
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