Background/Purpose: Disease activity measures used in SLE clinical studies, including the SLEDAI (SLE Disease Activity Index) and BILAG (British Isles Lupus Assessment Group) index are challenging due to potential scoring pitfalls, and require extensive training and experience. This leaves a busy clinician with limited tools for tracking SLE patients to ensure quality care and documentation of treatment targets. The SLEDAI physician’s global assessment (PGA) is simple to learn and efficient to use, but compresses assessment of moderate to severe disease into a small region of the scale, limiting the ability to evaluate change. Also, no organ specific evaluation is performed.

Directed Intuitive Assessment of Lupus (DIAL) is a pilot application composed of seven anchored visual analogue scores (0-100mm each) representing the most common organs affected by SLE: mucocutaneous, neuropsychiatric, musculoskeletal, cardiorespiratory, renal, hematologic, or other (for more rare conditions). The physician selects the scale(s) for active organ(s) and rates disease severity using simple anchored landmarks based on the SLEDAI system: 0=no disease, 1=mild, 2=moderate, and 3=severe. Only features due to active SLE are rated. The total DIAL score is the sum of scores for active organs. This enables both organ-specific distinctions and a wider spectrum of change.

This study was initiated to compare BILAG, SLEDAI and DIAL scores.

Methods: A prospective real world clinic exercise was performed by evaluating 91 consecutive SLE patients in two rheumatology clinics. SLEDAI, BILAG, and DIAL scores were recorded. The level of agreement was determined by the strength of Spearman rank correlations.

Results: The study included 86 women and 5 men, mean age 42.1 years, 54% Caucasian, 31% African, 14% Asian, 24% Hispanic. 70(77%) patients were taking antimalarials, 53(58%) immunomodulators, and 40(44%) prednisone (11>10 mg). 17(19%) were rated as flaring at the time of the assessment. The median (range) SLEDAI was 4.0(0-28), BILAG 2004 score 8.0(0-32) representing a broad spectrum from minimal to severe disease. The median PGA (on 100mm scale) was 38(4-92) vs the total DIAL score 50(0-268). 33 patients were rated moderate-severe (≥1.5 on PGA) and their median PGA was 66(50-92) vs DIAL 100(50-268) confirming a wider distinction potential of comparative scores. The total DIAL score correlated well with the PGA, SLEDAI, and BILAG summary scores (correlation coefficients of 0.90, 0.82, and 0.93 respectively, p<0.0000002 for all). The DIAL scores for musculoskeletal and mucocutaneous domains correlated with the corresponding BILAG domain scores at 0.92 and 0.94 (p<0.0000002). The DIAL index took only a few seconds to score.

Conclusion: This simple, intuitive measurement of disease severity performed reliably at two clinics. The advantage over the PGA is ability to distinguish involvement of different systems and more range to assess change in moderate/severe disease. Community input, refinement and formal validation of the DIAL system is planned. The final product of this work (which could be amenable to paper or encrypted electronic applications) could improve treatment justification, documentation of progress and standard of care for lupus patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/directed-intuitive-assessment-of-lupus-the-dial-system-for-real-world-clinics-correlates-well-with-bilag-and-sledai/