Medical Crossfire®: Improving Health Outcomes for Patients with Systemic Lupus Erythematosus (SLE)
Release Date: May 31, 2018
Expiration Date: May 31, 2019
Media: Internet - based
For the first time in decades, treatment options for patients with systemic lupus erythematosus (SLE) are expanding, offering patients new hope for living a longer, healthier life and reducing the burden of disease. With these advances, active lupus is no longer the leading cause of morbidity and mortality. Patients are now facing significant morbidity from potentially preventable conditions and clinicians must learn how to address these new problems through improved preventive care and treatment of lupus flares. During this Medical Crossfire®, expert faculty will engage in a multidisciplinary roundtable discussion that includes a rheumatologist, dermatologist, and nurse practitioner. The panel provides key guidance for identifying and treating lupus flares, improving preventive care, and engaging patients in treatment decisions in order to improve their treatment adherence. The safety and efficacy of new and emerging treatments will also be addressed so that clinicians are prepared to provide their patients with the most up-to-date treatment options.
Acknowledgement of Commercial Support
Instructions for This Activity and Receiving Credit
This CME activity is intended for rheumatologists, primary care providers, nurse practitioners (NPs), physician assistants, nurses, and other health care professionals who treat patients with SLE.
Upon completion of this CME activity, you should be better prepared to:
- Review the importance of preventive care for reducing SLE-associated morbidity and mortality
- Describe effective methods to diagnose disease flares in patients and implement effective management in a timely fashion
- Discuss the existing evidence that supports the use of currently available SLE treatments and the data for drug therapeutics that are in late-stage clinical trials
- Develop methods to enhance the patient-physician relationship to improve patients’ adherence to long-term SLE treatment
Faculty, Staff, and Planners' Disclosures
Paul P. Doghramji, MD, FAAFP
Collegeville Family Practice
Medical Director, Health Services
Disclosure: Paul P. Doghramji, MD, FAAFP has no financial information to disclose.
Amy X. Ma, DNP, FNP-BC
Harriet Rothkopf Heilbrunn School of Nursing
Long Island University – Brooklyn
FIT Health Service
New York, New York
Disclosure: Amy X. Ma, DNP, FNP-BC has no financial information to disclose.
Maureen McMahon, MD, MS
Associate Professor of Medicine/Rheumatology
UCLA David Geffen School of Medicine
Division of Rheumatology
Los Angeles, California
Disclosure: Maureen McMahon, MD, MS - Consulting: AstraZeneca, GlaxoSmithKline
Victoria P. Werth, MD
Department of Dermatology and Medicine (Rheumatology)
University of Pennsylvania School of Medicine
Disclosure: Victoria P. Werth, MD - Grant/Research Support: Celgene, Janssen, Pfizer, Biogen, Corbus Pharmaceuticals, LuCIN, Genentech, Syntimmune, AstraZeneca
Consulting: Celgene, Medimmune, Resolve, Neovcs, ACI, Immune Pharmaceuticals, Genentech, Idera, Octapharma, BSL Behring, Janssen, Lilly, Pfizer, Biogen, Bristol-Myers Squibb, Biostrategies, Gilead, Amgen, Medscape, Principia, Nektar, Syntimmune, Incyte, EMD Sorona
The staff of Physicians' Education Resource®, LLC have no relevant financial relationships with commercial interests.
Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians, and is a provider approved by the California Board of Registered Nursing (CBRN).
Physicians' Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™ and for 1.5 contact hours for nurses. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This activity may or may not discuss investigational, unapproved, or off-label uses of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to the diagnostic, treatment, and management options for a specific patient’s medical condition.
The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC, or any of the companies that provided commercial support for this activity.
PER Pulse™ Recaps
1 of 3
Diagnosis and Health Maintenance
The online continuing medical education activity A Multidisciplinary Approach to Improving Health Outcomes for Patients With Systemic Lupus Erythematosus (SLE) imparts healthcare providers with engaging instructions on how to identify and treat lupus and improve health outcomes for patients. Leading experts in lupus care Victoria Werth, MD, and Maureen McMahon, MD, MS, answer key questions, supported by the presentation of clinical science, about current and evolving treatment standards for lupus. This first of 3 PER Pulse™ Recaps from the program focuses on the diagnosis of lupus and the changing morbidity and mortality that patients with lupus currently face.
Dr Werth and Dr McMahon discuss the diagnosis of lupus and the evolving health maintenance needs of patients living with the disease.
- There are 11 criteria used to establish a diagnosis of lupus, and patients need to have at least 4 of these criteria to fit the diagnosis. However, if there is a strong suspicion of lupus and the patient does not fully meet the criteria, a referral to a rheumatologist would still be warranted.
- An antinuclear antibody (ANA) test should be performed in all patients suspected of having lupus, but it is important to remember that up to 25% of adults, and older adults in particular, can have a false-positive ANA. Additional laboratory studies that should be performed include the double-stranded DNA antibody, the Smith antibody, and antiphospholipid antibodies. Serology testing will be negative approximately 5% of the time in patients who have lupus.
- When a patient is given a diagnosis of lupus, the ANA titer does not need to be followed, as changes in titer are not clinically relevant. However, the double-stranded DNA titers can rise and complement levels can fall during or just before a flare. Therefore, these should be monitored regularly.
- Mortality rates have improved dramatically for patients with lupus, and 80% to 90% of patients will have a normal life span. Active lupus is no longer a major cause of death; cardiovascular disease, complications of renal failure, and malignancy now cause the majority of deaths. This has created a new need for health maintenance. Focus should be given to skin cancer prevention, osteoporosis screening, cardiovascular disease screening, monitoring for mood disorders, regular cancer screening, and keeping vaccinations up-to-date. Screening should be individualized to each patient’s own level of risk.
- Lifestyle modifications are an important part of improving the overall health of patients with lupus and should include smoking cessation, maintaining a healthy weight, eating a balanced diet, exercising regularly, and getting adequate sleep.
2 of 3
The online continuing medical education activity A Multidisciplinary Approach to Improving Health Outcomes for Patients With Systemic Lupus Erythematosus (SLE) imparts healthcare providers with engaging instructions on how to identify and treat lupus and improve health outcomes for patients. Leading experts in lupus care Victoria Werth, MD, and Maureen McMahon, MD, MS, answer key questions, supported by the presentation of clinical science, about current and evolving treatment standards for lupus. This second of 3 PER Pulse™ Recaps from the program focuses on lupus flares.
Dr Werth and Dr McMahon discuss the presentation and diagnosis of lupus flares.
- Lupus is a highly variable, heterogeneous disease with periods of quiescence that are interspersed with disease flares ranging from mild to severe and even life-threatening. The course of lupus can be different for every patient, and there is no standard course, which makes treating this disease a challenge. Dr McMahon offers this suggestion to aid in diagnosing lupus flares earlier: “It is important to educate patients about lupus flare symptoms and to teach them to recognize their own particular signs.”
- Identifying disease flares can often be challenging because they can be difficult to discern from drug toxicities or adverse effects, chronic organ damage, and patient comorbidities. According to Dr McMahon, flares can also be “difficult to distinguish from an infection, and on top of that, sometimes infections can trigger a flare, so you can have both things going on at once.” Therefore, it is important to consider each patient individually, along with the entire clinical picture, when evaluating a potential flare.
- Diagnosing a flare requires a careful history and physical examination. The evaluation should include a complete blood count, double-stranded DNA titer, complement, comprehensive metabolic panel, C-reactive protein, sedimentation rate, and urine protein/creatinine ratio or a 24-hour urine collection in certain circumstances. Depending on the patient’s presentation, further evaluation may be necessary.
- Keep in mind that a flare can be present even if the diagnostic work-up is normal.
- More severe flares may be associated with hemolytic anemia, leukopenia, thrombocytopenia, low albumin level, proteinuria, or elevated creatinine level.
- Patients should be followed regularly even if their disease is quiescent. At a minimum, patients should be seen annually for a follow-up of their lupus and for health maintenance.
3 of 3
Treatment and Adherence
The online continuing medical education activity A Multidisciplinary Approach to Improving Health Outcomes for Patients With Systemic Lupus Erythematosus (SLE) imparts healthcare providers with engaging instructions on how to identify and treat lupus and improve health outcomes for patients. Leading experts in lupus care Victoria Werth, MD; Maureen McMahon, MD, MS; and Amy Ma, RNP, answer key questions, supported by the presentation of clinical science, about current and evolving treatment standards for lupus. This third of 3 PER Pulse™ Recaps from the program focuses on the treatment of lupus.
Dr Werth, Dr McMahon, and nurse practitioner Amy Ma discuss the treatment of lupus and how to improve patients’ adherence to the treatment of this chronic disease.
- The treatment of lupus needs to be individualized to meet each patient’s needs and the severity of their disease. Dr McMahon indicates that “when a patient initially presents, I usually will treat any symptoms that they have. And then, most patients I’ll put on hydroxychloroquine. It helps to prevent the frequency and severity of flares, but also long term, it tends to prevent damage that is associated with lupus.”
- Treating the skin symptoms of lupus involves antimalarials and sun protection. If the symptoms are refractory to initial treatment, topical steroids or nonsteroidal types of medications can be used, and if needed, treatment can be escalated to include quinacrine or an immunosuppressant, such as methotrexate or mycophenolate mofetil.
- Patients who are refractory to treatment and have autoantibodies and/or other serologic abnormalities, such as low complement, may benefit from the addition of belimumab to their treatment regimen.
- When providers are selecting treatment, a woman’s desire for pregnancy must be considered because many drugs are contraindicated during pregnancy.
- Once the background medication is established, the focus of treatment moves to treating flares and the symptoms that patients experience. Ideally, patients should be tapered down from some of their maintenance medications until they present with a new flare, and steroids should be used only during treatment initiation or as a bridge to starting new treatments.
- The medications used to treat lupus are often associated with significant adverse effects that require regular monitoring or that can limit the clinical use of medications. Mycophenolate is often associated with gastrointestinal adverse effects; calcineurin inhibitors can cause hypertension; patients receiving antimalarials need regular eye examinations; use of steroids for more than 3 months increases the risk of osteoporosis; and methotrexate use requires the avoidance of alcohol and the regular monitoring of complete blood count and liver function tests.
- Patients are often frustrated with the challenges associated with treatment, and this frustration can lead to low treatment adherence. Helping address the difficulties patients face by simplifying treatment regimens, recognizing the financial challenges patients are experiencing, and limiting treatment adverse effects can help improve adherence.
- Nurse practitioner Amy Ma suggests, “You have to develop a relationship so that the patient trusts you, trusts your professional judgment, and they understand. You have to spend time with them and say, ‘We understand what you’re taking the medicine for and what’s helping, and there are side effects for sure, and this is how we’re going to address that problem.’”