PoM No 9, 2013

Publication of the Month

September 09/13: Evidence-based study to determine the optimal frequency of follow-up visits in asymptomatic SLE patients  

 

Key messages:

  • Important indicators of disease flare are not recognised by SLE patients and may only be detected in a thorough clinical and laboratory evaluation.
  • Even asymptomatic SLE patients should be followed with clinical and laboratory measures at 3-4 month intervals.
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Gladman DD, Ibaňez D, Ruiz I, Urowitz MB.
Recommendations for Frequency of Visits to Monitor Systemic Lupus Erythematosus in Asymptomatic Patients: Data from an Observational Cohort Study J. Rheumatol. 2013; 40: 630-633  

     

Background: Both the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) have developed guidelines regarding follow-up in systemic lupus erythematosus (SLE) patients with mild, stable disease but these have been based on opinion as no data were available from which to derive evidence-based monitoring intervals. Given that “the cornerstone of managing SLE is lifelong patient monitoring to detect flares of disease early and to institute prompt, appropriate therapy”, this group decided to observe a cohort of patients to see if there were disease manifestations that would not be obvious to a patient without clinical evaluation or laboratory testing (solitary, silent new features) and which might lead a physician to adopt a different management approach in order to avoid a disease flare. 

Summary: 515 patients were observed over a total of 3126 visits. In 126 (24.5%), the silent variable of interest was the sole manifestation of SLE. The commonest manifestations were renal, low complement and DNA antibodies followed by thrombocytopenia, low haemoglobin and elevated creatinine.   

Conclusions: One in 4 patients with SLE will have a solitary silent variable of interest that could only be detected by routine laboratory follow-up over a two year period. This suggests that even patients with mild or inactive SLE should be followed at 3-4 month intervals.   

Comment: This is the first study to look at the appropriate interval for monitoring asymptomatic SLE patients. Important but otherwise silent manifestations of disease flare were found in almost 5% of visits and in a quarter of the patients. The study fits with a level of evidence category 2b (based on the Oxford Center for Evidence Based Medicine – levels of evidence) so justifies the authors’ recommendation that both ACR and EULAR recommendations be amended to reflect this finding: “that patients with mild or inactive disease be followed at intervals of 3-4 months."

 

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.