Nicolai Leuchten

Toward new criteria for systemic lupus erythematosus—a standpoint:

While clearly different in their aims and means, classification and diagnosis both try to accurately label the disease patients are suffering from. For systemic lupus erythematosus (SLE), this is complicated by the multi-organ nature of the disease and by our incomplete understanding of its pathophysiology. Hallmarks of SLE are the presence of antinuclear antibodies (ANA), and multiple immune-mediated organ symptoms that are largely independent. In an attempt to overcome limitations of the current sets of SLE classification criteria, a new four-phase approach is being developed, which is jointly supported by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). This review attempts to delineate the performance of the current sets of criteria, the reasons for the decision for classification, and not diagnostic, criteria, and to provide a background of the current approach taken.

Performance of Antinuclear Antibodies for Classifying Systemic Lupus Erythematosus: A Systematic Literature Review and Meta-Regression of Diagnostic Data

To review the published literature on the performance of indirect immunofluorescence (IIF)–HEp‐2 antinuclear antibody (ANA) testing for classification of systemic lupus erythematosus (SLE).

Early symptoms of systemic lupus erythematosus (SLE) recalled by 339 SLE patients

Objective The European League Against Rheumatism and the American College of Rheumatology jointly embarked on a new classification criteria for systemic lupus erythematosus (SLE) project. Its first phase involved generation of a broad set of items potentially useful for classification of SLE. This study was undertaken to add the patient perspective to an expert Delphi approach and an early patient cohort study. Methods A national cross-sectional study was conducted. A self-report questionnaire was published in the “Schmetterling” (Butterfly), the quarterly journal of the German SLE patient association. Individuals with SLE were asked to anonymously complete the questionnaire, which asked for demographic details, organ manifestations, autoantibodies and symptoms. Results A total of 339 completed questionnaires out of 2498 were returned, a response rate of 13.6%; 83.2% reported they were ANA positive and 81.7% reported joint, 66.1% skin and 33.0% renal involvement. For the time before and in the first year after their SLE diagnosis, the majority reported fatigue (89.4%), joint pain (86.7%), photosensitivity (79.4%) and myalgia (76.1%). Of interest, more than half of the patients reported fever as an early symptom (53.7%). Conclusion For a Caucasian European SLE patient population, the overall characteristics suggest meaningful representation. While many symptoms were reported as expected, the high percentage of patients reporting fever and the significant number of patients with unexpected gastrointestinal complaints are of particular interest. These data add to the information on early SLE symptoms informing the development process of new SLE classification criteria.

Indication Criteria for Total Knee Arthroplasty in Patients with Osteoarthritis – A Multi-perspective Consensus Study

Background and Objectives Knee osteoarthritis (OA) is a significant public health burden. Rates of total knee arthroplasty (TKA) in OA vary substantially between geographical regions, most likely due to the lack of standardised indication criteria. We set out to define indication criteria for the German healthcare system for TKA in patients with knee OA, on the basis of best evidence and transparent multi-stakeholder consensus. Methods We undertook a complex mixed methods study, including an iterative process of systematic appraisal of existing evidence, Delphi consensus methods and stakeholder conferences. We established a consensus panel representing key German national societies of healthcare providers (orthopaedic surgeons, rheumatologists, pain physicians, psychologists, physiotherapists), payers, and patient representatives. A priori defined consensus criteria were at least 70% agreement and less than 20% disagreement among the consensus panel. Agreement was sought for (1) core indication criteria defined as criteria that must be met to consider TKA in a normal patient with knee OA, (2) additional (not obligatory) indication criteria, (3) absolute contraindication criteria that generally prohibit TKA, and (4) risk factors that do not prohibit TKA, but usually do not lead to a recommendation for TKA. Results The following 5 core indication criteria were agreed within the panel: 1. intermittent (several times per week) or constant knee pain for at least 3 - 6 months; 2. radiological confirmation of structural knee damage (osteoarthritis, osteonecrosis); 3. inadequate response to conservative treatment, including pharmacological and non-pharmacological treatment for at least 3 - 6 months; 4. adverse impact of knee disease on patients quality of life for at least 3 - 6 months; 5. patient-reported suffering/impairment due to knee disease. Additional indication criteria, contraindication criteria, and risk factors for adverse outcome were also agreed by a large majority within the multi-perspective stakeholder panel. Conclusion The defined indication criteria constitute a prerequisite for appropriate provision of TKA in patients with knee OA in Germany. In eligible patients, shared-decision making should eventually determine if TKA is performed or not. The next important steps are the implementation of the defined indication criteria, and the prospective investigation of predictors of success or failure of TKA in the context of routine care provision in Germany.

SAT0415 Performance of Anti-Nuclear Antibodies (ANA) for Classifying Systemic Lupus Erythematosus (SLE): A Systematic Literature Review and Meta-Regression of Diagnostic Data

Background EULAR and ACR have jointly funded a project to improve existing SLE classification criteria, aiming at earlier and more accurate classification of the disease. This abstract reports on an early phase of that project. ANA constitute the immunological hallmark of SLE, and ANA testing is widely used for SLE diagnosis based on its reportedly high sensitivity. Although indirect immunofluorescence on Hep-2 cells (IIF-Hep2) is considered the gold standard of ANA testing (1), the performance of different ANA titers and the possibility to include ANA as entry criterion for the classification of SLE have not been systematically evaluated. Objectives To review the published literature on the performance of IIF-Hep2 ANA testing for the classification/diagnosis of SLE. Methods A systematic literature search was conducted in MEDLINE and EMBASE for articles published between January 1990 and March 2014. The research question was structured according to PICO (Population, Intervention, Comparator, Outcome) format rules, and PRISMA recommendations were followed where appropriate. Meta-regression analysis for diagnostic tests was performed using the ANA titer as independent variable and sensitivity and specificity as dependent variables. Results A total of 3,919 publications were screened in abstract and title and 623 articles were evaluated in full-text. Of these, 60 matched the eligibility criteria and were included in the analysis. The included studies comprised 10,089 SLE patients in total, of whom 9,587 (95.0%) were reported to be ANA positive at various titers. For ANA at titers of 1:40, 1:80 and 1:160, meta-regression gave sensitivity values of 98.8% (95% confidence interval [CI] 98.0-99.3%), 98.1% (CI 97.1-98.8%) and 95.4% (CI 93.0–97.0%), respectively. The corresponding specificities were 75.1% (CI 64.3-83.5%), 83.3% (CI 74.9-89.3%) and 93.2% (CI 88.6-96.0%), respectively. Conclusions The results of this systematic literature search and meta-regression confirm the high sensitivity of a positive ANA test for SLE. While no decision has so far been made, these data suggest that ANA at a titer of 1:80 could be a reasonable entry criterion for SLE classification criteria. References Agmon-Levin et al, Ann Rheum Dis 2014; 73: 17ff Disclosure of Interest None declared

ANA as an Entry Criterion in SLE Classification

Thoughtful and eloquent as always, Drs. Pisetsky and Lipsky in their letter (1) highlight a critical point in the current SLE classification criteria project jointly supported by EULAR and ACR: if ANA positivity is to be the entry criterion, the sensitivity of the assay to detect ANA and that of ANA positivity for SLE are both important. Indeed, this issue has been a matter constantly discussed by the classification criteria steering committee since the beginning of the project. Our tenet is not that various ANA assays are comparable, but that ANA positivity is optimally positioned as an entry criterion for the classification of SLE (2). This article is protected by copyright. All rights reserved.

Relevant Concepts of Functioning for Patients With Systemic Lupus Erythematosus Identified in a Delphi Exercise of Experts and a Literature Review

To identify in a Delphi exercise of international systemic lupus erythematosus (SLE) experts and a systematic literature review the most relevant concepts that impact on the functioning of SLE patients.

Rheumatoide Arthritis ausbremsen

ZusammenfassungDie rheumatoide Arthritis ist eine chronische Erkrankung, die unbehandelt zu schweren Funktionseinschränkungen der Gelenke führt. Auch die Letalität der Betroffenen ist deutlich erhöht. Fortschritte in der medikamentösen Basistherapie ermöglichen heute aber fast immer eine gute Kontrolle der Erkrankung. Entscheidend ist jedoch die frühe Diagnose. Spätestens drei Monate nach Beschwerdebeginn muss die Basistherapie beginnen. Die Behandlung wird mit standardisierten Scores überwacht und gegebenenfalls angepasst. Neben der Basistherapie sind auch Schmerztherapie, Physio- und Ergotherapie unverzichtbar. Im Einzelfall können operative Verfahren erforderlich werden. Ein konsequentes multimodales Therapieregime kann den Krankheitsverlauf entscheidend verändern und Spätschäden reduzieren.