Application of the Doris Algorithm for the Definition of Disease Remission and Its Relation with Damage Accrual over a 2-Year Period in a Cohort of Italian Patients with Systemic Lupus Erythematosus Classified According to Clinical Disease Patterns

Francesca Dall'Ara¹, Laura Andreoli², Federica Migliorati³, Giuseppe Armentaro³, Micaela Fredi⁴, Micol Frassi⁵, Mara Taraborelli³, Franco Franceschini⁴, Stefano Calza⁶ and Angela Tincani³, ¹Department of Clinical and Experimental Sciences,Spedali Civili and University of Brescia, Brescia, Italy, Rheumatology and Clinical Immunology, Brescia, Italy, ²Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy, Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy, ³Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy, Rheumatology and Clinical Immunology, BRESCIA, Italy, ⁴Department of Clinical and Experimental Sciences, Spedali Civili and University of Brescia, Brescia, Italy, Rheumatology and Clinical Immunology, Brescia, Italy, ⁵Spedali Civili of Brescia, Brescia, Italy, Rheumatology and Clinical Immunology, BRESCIA, Italy, ⁶Unit of Biostatistics and Biomathematics & Unit of Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: remission and systemic lupus erythematosus (SLE)

Session Information

Date: Monday, October 22, 2018

Title: Systemic Lupus Erythematosus – Clinical Poster II: Biomarkers and Outcomes

Session Type: ACR Poster Session B

Session Time: 9:00AM-11:00AM

Background/Purpose: Systemic Lupus Erythematosus (SLE) is characterized by a fluctuating course. To achieve sustained remission is the ultimate goal of maintenance treatment. However the definition of remission is difficult in SLE. In 2014, an international Task Force named DORIS proposed four definitions of remission. The aim of this study was to evaluate the performance of the DORIS algorithm, to identify the frequency of remission as determined by DORIS for each clinical disease pattern, and to evaluate the impact of remission on damage accrual.

Methods: Monocentric retrospective study. Among all SLE patients followed at the Lupus Clinic between 2014 and 2017, we enrolled patients fulfilling the SLICC 2012 criteria who were visited at least once in 2017 and who had at least 5 biannual medical examinations in the previous 2 years. Definitions of remission according to DORIS and disease patterns are reported in Table 1. Damage accrual was measured by the SDI score¹.

Results: 101 SLE patients were enrolled for this study (94% female, mean age 45 years). 505 time-points were evaluated: 211 (42%) were defined as “remission” according to DORIS and in particular 181 (85.5%) were “remission on treatment”. 17.8% of patients were in remission in all the 5 time-points, vice versa 29.7% of patients never got into remission. 17.8% of patients have been in remission for 24 months, while 21.8% of patients less than 6 months. Mean duration of DORIS remission was 7.96 months. The most frequent disease patterns were RR (41,6%) and CQ (41,6%), while CA pattern was present in 16,8% of patients. DORIS remission was most frequently achieved in CQ pattern (65.2% of visits), less frequently in CA (5.9%). At the end of follow-up 50% of patients had a SDI≥1, and cumulative dosage of steroids was significantly associated to damage accrual (p:0.04 OR: 1.04 CI: 1.001-1.088). Moreover patients with at least one time-point in remission according to DORIS had a significantly lower damage accrual (p: 0.01) when compared to patients who never got into remission.

Conclusion: The DORIS algorithm is easy to be employed in clinical practice. In this cohort 30% of patients never achieved remission. Since damage accrual was associated with both cumulative dosage of steroids and unremitted disease, the goal in SLE management should be sustained remission with the lowest dose of steroids.

1)Gladman D, Ginzler E, Goldsmith C, Fortin P, Liang M, Urowitz M, et al. The development and initial validation of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for systemic lupus erythematosus. Arthritis Rheum. 1996;39:363–369.

Table 1: Definition of Remission according to DORIS; Definition of disease pattern. PGA: Physician Global Assessment; cSLEDAI: clinical SLEDAI (without anti-dsDNA and C3/C4 levels)

Definition of Remission	Clinical Items		Treatment
	cSLEDAI	PGA	Daily dose of prednisone	Antimalarials	Immunosuppressants/ Biologics
Remission “off treatment”	= 0	< 0.5	0	yes	no
Remission “on treatment”	= 0	< 0.5	≤ 5 mg	yes	yes
No Remission	≠0	≥0.5	>5 mg	yes	yes
Definition of disease patterns
Chronic active (CA)	Persistent disease activity over time with a cSLEDAI ≥1 in each visit for at least one year
Relapsing-remitting (RR)	Characterised by periods of disease activity with cSLEDAI ≥1 interspersed with periods of disease inactivity with cSLEDAI = 0 in different visits for at least one year
Clinically quiescent (CQ)	Defined as absence of disease activity with a cSLEDAI = 0 for at least one year

Disclosure: F. Dall'Ara, None; L. Andreoli, None; F. Migliorati, None; G. Armentaro, None; M. Fredi, None; M. Frassi, None; M. Taraborelli, None; F. Franceschini, None; S. Calza, None; A. Tincani, Bristol-Myers Squibb, 2,UCB, Inc., 5.

To cite this abstract in AMA style:

Dall'Ara F, Andreoli L, Migliorati F, Armentaro G, Fredi M, Frassi M, Taraborelli M, Franceschini F, Calza S, Tincani A. Application of the Doris Algorithm for the Definition of Disease Remission and Its Relation with Damage Accrual over a 2-Year Period in a Cohort of Italian Patients with Systemic Lupus Erythematosus Classified According to Clinical Disease Patterns [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/application-of-the-doris-algorithm-for-the-definition-of-disease-remission-and-its-relation-with-damage-accrual-over-a-2-year-period-in-a-cohort-of-italian-patients-with-systemic-lupus-erythematosus-c/. Accessed .

« Back to 2018 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/application-of-the-doris-algorithm-for-the-definition-of-disease-remission-and-its-relation-with-damage-accrual-over-a-2-year-period-in-a-cohort-of-italian-patients-with-systemic-lupus-erythematosus-c/