Session Information
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose: Systemic Lupus Erythematosus (SLE) is a multi-systemic inflammatory disease with extreme variability of its activity over time. We have described three main patterns: long quiescence (or remission), chronic activity and relapsing-remitting (or flare). Patients may move through a series of these activity states over time. To capture these complex fluctuations, we used a Multistate Markov model to describe and evaluate SLE disease activity patterns over time in a longitudinal lupus cohort.
Methods: SLE patients were followed up quarterly in Hopkins Lupus Cohort for 1- 28 years. Medication, disease activity (by, Physician Global Assessment (PGA) and SLE Disease Activity Index (SLEDAI), C3, C4, anti-dsDNA, antiphospholipid antibodies and urine protein/ creatinine ratio were recorded at each visit. For each patient, visits were divided into 1-year blocks. Any 1-year block with only one visit or patients followed for only 1 year were excluded. SLE disease activity patterns were defined using PGA and SLEDAI: Long Quiescent (LQ), SLEDAI/PGA=0 for all visits within 1-year blocks; Relapsing-Remitting (RR), periods of disease activity (SLEDAI/PGA>0) interspersed with periods of disease inactivity (SLEDAI/PGA=0) within 1-year block; Chronic Active (CA), SLEDAI/PGA scores >0 for all visits within 1-year block. Multistate Markov models were used to provide estimates of relative transition rates and identified predictors of change in disease activity patterns.
Results: 1735 SLE patients were included in this analysis. 92.3% were females, Mean+/-SD Age 32.8 +/- 13.1 years at diagnosis. 52.9% were Caucasian and 40.3% African American, the remainder had other ethnicity, mostly Asian. 127 patients died during follow up. Likelihood of deterioration (from LQ to RR; from RR to CA; from LQ to CA) was greater than improvement (from RR to LQ; from CA to RR; from CA to LQ). At year one, 63.6% remained in LQ, while at year two and year five, 58.2% and 84.1% had deteriorated from LQ pattern to either RR or CA pattern. From the RR pattern, the estimated probability for deterioration (to CA pattern) was higher than improvement (to LQ pattern), regardless of years since SLE diagnosis. Multivariate analysis (see table 1) identified that race/ethnicity (African American), low C3, low C4, ESR >20, taking prednisone or anti-hypertension drug were predictors for deterioration. Plaquenil improved survival. Table 1 Hazard Ratio and 95% confidence interval of Predictors of Transitions using Multivariate Analysis
| LQ -> RR | LQ -> CA | RR -> CA | RR -> LQ | CA -> LQ | CA -> RR | LQ -> Death | RR -> Death | CA -> Death | |
| RACE | |||||||||
|
African American |
1.15 (0.9,1.46) | 2.2 (0.78,6.26) | 1.81 (1.59,2.06)* | 0.72 (0.58,0.89) | 0.42 (0.15,1.2) | 0.8 (0.7,0.91) | 2.28 (0.54,9.59) | 1.57 (0.93,2.64) | 0.59 (0.31,1.12) |
|
Other |
0.89 (0.57,1.39) | 0.86 (0.11,6.77) | 1.41 (1.09,1.83) | 1.31 (0.91,1.87) | 1.89 (0.39,9.19) | 0.97 (0.75,1.26) | / | 0.4 (0.05,2.94) | / |
|
Caucasian |
Ref | Ref | Ref | Ref | Ref | Ref | Ref | Ref | Ref |
| Current Smoking | 1.15 (0.86,1.53) | 1.09 (0.34,3.48) | 1.03 (0.88,1.21) | 1.18 (0.92,1.53) | 0.58 (0.13,2.56) | 0.83 (0.71,0.98) | / | 2.06 (1.25,3.4) | 2.5 (1.31,4.77) |
| Urine Protein Creatine Ratio | 1.23 (0.68,2.24) | / | 1.11 (0.96,1.28) | 0.48 (0.34,0.68)* | 0.75 (0.21,2.76) | 1.03 (0.9,1.19) | 2.89 (0.32,25.73) | 1.79 (1.11,2.89) | 2.15 (1.1,4.19) |
| Low C3 | 2.49 (0.92,6.75) | / | 1.75 (1.51,2.03)* | 0.38 (0.24,0.59)* | / | 0.93 (0.8,1.08) | / | 1.46 (0.82,2.59) | 1.86 (0.9,3.84) |
| Low C4 | 0.89 (0.1,8.09) | / | 1.56 (1.32,1.83)* | 0.2 (0.1,0.4)* | / | 0.96 (0.82,1.13) | / | 1.69 (0.88,3.26) | 1.13 (0.52,2.46) |
| ESR.c | 0.93 (0.75,1.14) | 1.26 (0.5,3.18) | 1.28 (1.13,1.45)* | 0.68 (0.56,0.81)* | 1.38 (0.49,3.92) | 0.99 (0.87,1.12) | 3.44 (0.64,18.43) | 2.4 (1.34,4.29) | 1.37 (0.64,2.92) |
| Prednisone | 1.21 (0.97,1.51) | 1.06 (0.38,2.94) | 1.06 (0.94,1.19) | 0.65 (0.54,0.78)* | 1.19 (0.44,3.24) | 1.02 (0.9,1.16) | 3.96 (0.92,17.08) | 3.83 (1.99,7.38)* | 2.34 (1,5.44) |
| Plaquenil | 1.4 (1.13,1.74) | 1.55 (0.59,4.08) | 1.28 (1.12,1.45)* | 0.98 (0.81,1.18) | 3.48 (0.77,15.67) | 1.06 (0.93,1.21) | 0.94 (0.23,3.81) | 0.37 (0.23,0.59)* | 0.7 (0.37,1.33) |
| Anti Hypertension Drug | 1.05 (0.86,1.28) | 0.36 (0.13,0.99) | 1.08 (0.96,1.21) | 1.1 (0.92,1.31) | 0.74 (0.28,1.96) | 0.96 (0.85,1.08) | 1.45 (0.35,5.97) | 2.99 (1.7,5.26)* | 2.02 (1.03,3.97) |
* P value < 0.0006, accounting for multiple comparison
Conclusion: 1 year after SLE diagnosis, more than half of patient with LQ deteriorated. Patients in RR were more likely to deteriorate than improve. Plaquenil showed great promise in improving survival.
To cite this abstract in AMA style:
Fu W, Petri M. A Longitudinal Analysis of Change in Lupus Disease Activity Pattern in Hopkins Lupus Cohort Using a Multistate Markov Model Approach [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/a-longitudinal-analysis-of-change-in-lupus-disease-activity-pattern-in-hopkins-lupus-cohort-using-a-multistate-markov-model-approach/. Accessed .« Back to 2016 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-longitudinal-analysis-of-change-in-lupus-disease-activity-pattern-in-hopkins-lupus-cohort-using-a-multistate-markov-model-approach/