GRADE-Based Recommendations for the Diagnosis and Monitoring of Systemic Lupus Erythematosus in Canada

Stephanie Keeling¹, Zainab Alabdurubalnabi², J. Antonio Avina-Zubieta³, Susan Barr⁴, Louise Bergeron⁵, Sasha Bernatsky⁶, Josiane Bourré-Tessier⁷, Ann E. Clarke⁸, Alexandra Baril-Dionne⁹, Jan Dutz², Stephanie Ensworth¹⁰, Aurore Fifi-Mah¹¹, Paul R. Fortin¹², Dafna D Gladman¹³, Derek Haaland¹⁴, John G. Hanly¹⁵, Linda T Hiraki¹⁶, Sara Hussein⁹, Kimberly Legault¹⁷, Deborah M. Levy¹⁶, Lily Lim¹⁸, Mark Matsos¹⁹, Emily McDonald²⁰, Jorge Medina-Rosas²¹, Jordi Pardo Pardo²², Christine A. Peschken²³, Christian Pineau²⁴, Janet E. Pope²⁵, Tamara Rader²⁶, Jennifer Reynolds², Earl Silverman¹⁶, Manon Suitner⁹, Konstantinos Tselios²⁷, Murray Urowitz²⁸, Zahi Touma²⁹, Evelyne Vinet³⁰ and Nancy Santesso¹⁷, ¹Department of Medicine, University of Alberta, Division of Rheumatology, Edmonton, AB, Canada, ²Medicine, University of British Columbia, Vancouver, BC, Canada, ³Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada, ⁴Medicine, University of Calgary, Calgary, AB, Canada, ⁵Canadian Arthritis Patient Alliance, Toronto, ON, Canada, ⁶Divisions of Rheumatology and Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, QC, Canada, ⁷Rheumatology, University of Montreal, Montreal, QC, Canada, ⁸Division of Rheumatology, University of Calgary, Calgary, AB, Canada, ⁹Université de Montréal, Montreal, QC, Canada, ¹⁰University of British Columbia, Vancouver, BC, Canada, ¹¹University of Calgary, Calgary, AB, Canada, ¹²Medicine, CHU de Quebec - Universite de Laval, Quebec, QC, Canada, ¹³Centre for Prongosis Studies in The Rheumatic Diseases, Toronto Western Hospital, Krembil Research Institute, Toronto, ON, Canada, ¹⁴Rheumatology, Clinical Immunology & Allergy, McMaster University, Barrie, ON, Canada, ¹⁵Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS, Canada, ¹⁶Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada, ¹⁷McMaster University, Hamilton, ON, Canada, ¹⁸Hospital for Sick Children, Toronto, ON, Canada, ¹⁹Medicine, McMaster University, McMaster, ON, Canada, ²⁰Medicine, McGill University, Montreal, QC, Canada, ²¹Rheumatology, Universidad de la Sabana, Bogota, Colombia, ²²Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada, ²³RR 149G, Univ of Manitoba, Winnipeg, MB, Canada, ²⁴Division of Rheumatology, McGill University Health Centre, Montreal, QC, Canada, ²⁵Department of Medicine, Division of Rheumatology, University of Western Ontario, St Joseph's Health Care, London, ON, Canada, ²⁶The Ottawa Hospital - General Campus, Trials Search Coordinator Knowledge Translation Specialist Cochrane Musculoskeletal Group Centre for Practice Changing Research, Ottawa, ON, Canada, ²⁷Medicine, University of Toronto, Toronto, ON, Canada, ²⁸Centre for Prognosis Studies in the Rheumatic Diseases, University of Toronto, Toronto Western Hospital, Toronto, ON, Canada, ²⁹Rheumatology, University of Toronto, Division of Rheumatology, Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada, ³⁰Divisions of Rheymatology and Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: diagnosis, guidelines and systemic lupus erythematosus (SLE)

Session Information

Date: Monday, November 6, 2017

Title: Systemic Lupus Erythematosus – Clinical Aspects and Treatment Poster II: Damage and Comorbidities

Session Type: ACR Poster Session B

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

Background/Purpose: To develop GRADE-based recommendations for the diagnosis and monitoring of systemic lupus erythematosus patients in Canada.

Methods: Recommendations were developed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. The Canadian SLE Working Group (panel of Canadian rheumatologists and patient representative from CAPA (Canadian Arthritis Patient Alliance)) was created. Questions for recommendation development were identified based on a survey of SLE practice patterns of Canadian Rheumatology Association members. Systematic literature reviews of randomized controlled trials and observational studies were conducted. Evidence to Recommendation Tables were prepared and presented to the panel at two face-to-face meetings for discussion and voting during and post-meeting online.

Results: There are fourteen recommendations for diagnosing and monitoring lupus patients (Table 1). Three recommendations focused on diagnosis, disease activity and damage assessment and suggested a validated disease activity score per visit and annual damage score. One strong recommendation was made for cardiovascular risk assessment and conditional recommendations for osteoporosis (2) and osteonecrosis (1). Three conditional recommendations were made for peripartum assessments, one on cervical cancer screening, and two on hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination.

Conclusion: These are the first GRADE-based recommendations for the diagnosis and monitoring of SLE internationally. Evidence is moderate to low quality resulting in more conditional versus strong recommendations. Additional studies and special attention to pediatric lupus populations and patient preferences are needed.

Table 1. Summary of Recommendations With Strength of Evidence for the Diagnosis and Monitoring of SLE in Canada

Recommendation	Strength of Recommendation	Quality of Evidence
1. We recommend that all adult and pediatric patients suspected of SLE be referred to a lupus specialist, most often a rheumatologist, to confirm diagnosis and be involved in ongoing care	Strong	Moderate
2. For adult and pediatric patients with SLE, we suggest assessing disease activity with a validated instrument of disease activity during baseline and follow up visits.	Conditional	Low
3. For adult and pediatric patients with SLE, we suggest assessing disease damage annually with a validated measure.	Conditional	Low
4. For adult lupus patients, we recommend that indicators of obesity, smoking status, diabetes, blood pressure and a basic lipid profile be measured upon diagnosis of SLE and be reassessed periodically according to current recommendations in the general population and be used to inform the cardiovascular risk assessment.	Strong	Moderate
5. For adult patients with SLE, we suggest assessing the risk of osteoporosis and fractures every 1 to 3 years using a detailed history and focused physical examination, and measuring bone mineral density in patients with other risk factors according to recommendations in the general population.	Conditional	Low
6. For all adults with SLE, we suggest screening 25-hydroxyvitamin D as part of the assessment for risk of osteoporosis and fractures	Conditional	Low
7. For adult patients with SLE who do not have clinical symptoms suggestive of osteonecrosis, we suggest not screening for or performing investigations for osteonecrosis. For patients who have suspected clinical symptoms of osteonecrosis, we suggest radiographs as the initial imaging modality rather than MRI or bone scan with SPECT according to recommendations in the general population.	Conditional	Low
8. For women with SLE, we suggest that anti-Ro and anti-La antibodies be measured immediately prior to pregnancy or during the first trimester.	Conditional	Low
9. For pregnant women with SLE, we suggest that uterine and umbilical Doppler studies be performed in the second or third trimester, or at the time of a suspected flare.	Conditional	Low
10. For women with prior or active lupus nephritis who are pregnant, we suggest measuring serum creatinine and urine protein to creatinine ratio every 4-6 weeks, or more frequently if clinically indicated. We suggest blood pressure and urinalysis be measured prior to pregnancy and every 4-6 weeks until 28 weeks, every 1-2 weeks until 36 weeks and then weekly until delivery.	Conditional	Low
11. All female adult patients with SLE who are or have been sexually active, regardless of sexual orientation, we suggest annual cervical cancer screening rather than screening every 3 years at least up to the age of 69.	Conditional	Low
12. We recommend that adults and children with SLE receive an annual inactivated influenza vaccination in a single dose.	Strong	Moderate
13/14. For adults and pediatric patients with a diagnosis of SLE and high-risk behaviours for HBV and/or HCV acquisition, we recommend screening for Hepatitis B surface antigen and/or Hepatitis C and repeating according to recommendations for the general population. For patients being considered for immunomodulatory therapy, we suggest screening for HBV before starting treatment	Conditional	Low

Disclosure: S. Keeling, None; Z. Alabdurubalnabi, None; J. A. Avina-Zubieta, None; S. Barr, None; L. Bergeron, None; S. Bernatsky, None; J. Bourré-Tessier, None; A. E. Clarke, UCB, 2; A. Baril-Dionne, None; J. Dutz, None; S. Ensworth, None; A. Fifi-Mah, None; P. R. Fortin, None; D. D. Gladman, Amgen, AbbVie, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB., 2; D. Haaland, None; J. G. Hanly, None; L. T. Hiraki, None; S. Hussein, None; K. Legault, None; D. M. Levy, None; L. Lim, None; M. Matsos, None; E. McDonald, None; J. Medina-Rosas, None; J. Pardo Pardo, None; C. A. Peschken, None; C. Pineau, None; J. E. Pope, AbbVie, Amgen, Bayer, BMS, Celtrion, Eli Lilly and Company, Merck, Novartis, Pfizer, Roche, UCB, 5,Amgen, Bayer, BMS, GSK, Merck, Novartis, Pfizer, Roche, UCB, 2; T. Rader, None; J. Reynolds, None; E. Silverman, None; M. Suitner, None; K. Tselios, None; M. Urowitz, None; Z. Touma, None; E. Vinet, None; N. Santesso, None.

To cite this abstract in AMA style:

Keeling S, Alabdurubalnabi Z, Avina-Zubieta JA, Barr S, Bergeron L, Bernatsky S, Bourré-Tessier J, Clarke AE, Baril-Dionne A, Dutz J, Ensworth S, Fifi-Mah A, Fortin PR, Gladman DD, Haaland D, Hanly JG, Hiraki LT, Hussein S, Legault K, Levy DM, Lim L, Matsos M, McDonald E, Medina-Rosas J, Pardo Pardo J, Peschken CA, Pineau C, Pope JE, Rader T, Reynolds J, Silverman E, Suitner M, Tselios K, Urowitz M, Touma Z, Vinet E, Santesso N. GRADE-Based Recommendations for the Diagnosis and Monitoring of Systemic Lupus Erythematosus in Canada [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/grade-based-recommendations-for-the-diagnosis-and-monitoring-of-systemic-lupus-erythematosus-in-canada/. Accessed .

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