Psychosis in Systemic Lupus Erythematosus: Results from an International, Inception Cohort Study

John G. Hanly¹, Qiuju Li², Li Su³, Murray Urowitz⁴, Caroline Gordon⁵, Sang-Cheol Bae⁶, Juanita Romero-Díaz⁷, Jorge Sanchez-Guerrero⁴, Sasha Bernatsky⁸, Ann E. Clarke⁹, Daniel J. Wallace¹⁰, David A. Isenberg¹¹, Anisur Rahman¹², Joan T. Merrill¹³, Paul R. Fortin¹⁴, Dafna D Gladman¹⁵, Ian N. Bruce¹⁶, Michelle Petri¹⁷, Ellen M. Ginzler¹⁸, Mary Dooley¹⁹, Kristján Steinsson²⁰, Rosalind Ramsey-Goldman²¹, Asad A Zoma²², Susan Manzi²³, Ola Nived²⁴, Andreas Jönsen²⁴, Munther A Khamashta²⁵, Graciela S. Alarcón²⁶, Ronald F van Vollenhoven²⁷, Cynthia Aranow²⁸, Meggan Mackay²⁸, Guillermo Ruiz-Irastorza²⁹, Manuel Ramos-Casals³⁰, S. Sam Lim³¹, Murat Inanc³², Kenneth C. Kalunian³³, Søren Jacobsen³⁴, Christine A. Peschken³⁵, Diane L. Kamen³⁶, Anca Askanase³⁷, Chris Theriault³⁸ and Vernon Farewell³⁹, ¹Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS, Canada, ²MRC Biostatistics Unit, Cambridge, United Kingdom, ³Nova Scotia Rehab Site, Division of Rheumatology, Capital Health and Dalhousie University, Halifax, NS, Canada, ⁴University of Toronto Lupus Research Program, Toronto Western Hospital, Toronto, ON, Canada, ⁵Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom, ⁶Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea, Republic of (South), ⁷Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion, Mexico City, Mexico, ⁸Divisions of Rheumatology and Clinical Epidemiology, The Research Institute of the McGill University Health Centre, Montreal, QC, Canada, ⁹Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada, ¹⁰Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA, ¹¹University College London, London, United Kingdom, ¹²Rayne Institute, University College London, London, United Kingdom, ¹³Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, ¹⁴Medicine, CHU de Québec - University of Laval, Quebec, QC, Canada, ¹⁵Krembil Research Institute, Toronto Western Hospital, Toronto, ON, Canada, ¹⁶Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom, ¹⁷Johns Hopkins University School of Medicine, Baltimore, MD, ¹⁸Rheumatology, SUNY Downstate Medical Center, Brooklyn, NY, ¹⁹Dooley Rheumatology, Chapel Hill Doctors, Chapel Hill, NC, ²⁰Rheumatology, Univ. Hospital, Reykjavik, Iceland, ²¹FSM, Northwestern University, Chicago, IL, ²²Lanarkshire Center for Rheumatology, Hairmyres Hospital, East Kilbride, East Kilbride, Scotland, United Kingdom, ²³Autoimmunity Institute and Medicine Institute, Allegheny Health Network, Pittsburgh, PA, ²⁴Rheumatology, Lund University, Department of Clinical Sciences, Lund, Sweden, ²⁵Graham Hughes Lupus Research Laboratory, The Rayne Institute, London, United Kingdom, ²⁶University of Alabama at Birmingham, Birmingham, AL, ²⁷Unit for clinical therapy research (ClinTRID), Karolinska Institute, Stockholm, Sweden, ²⁸The Feinstein Institute for Medical Research, Manhasset, NY, ²⁹Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain, ³⁰Laboratory of Systemic Autoimmune Diseases “Josep Font”, CELLEX, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Systemic Autoimmune Diseases, ICMID, Hospital Clinic, Barcelona, Spain, Barcelona, Spain, ³¹Emory University School of Medicine, Atlanta, GA, ³²Department of Internal Medicine, Division of Rheumatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, ³³Division of Rheumatology, Allergy and Immunology, UCSD School of Medicine, La Jolla, CA, ³⁴Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, ³⁵RR 149G, University of Manitoba, Winnipeg, MB, Canada, ³⁶Medicine/Rheumatology & Immunology, Medical University of South Carolina, Charleston, SC, ³⁷Rheumatology, Columbia University, College of Physician and Surgeons, New York, NY, ³⁸Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS, Canada, ³⁹Medicine, Division of Rheumatology, Capital Health and Dalhousie University, Halifax, NS, Canada

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: neuropsychiatric disorders and quality of life, SLE

Session Information

Date: Tuesday, October 23, 2018

Title: 5T111 ACR Abstract: SLE–Clinical IV: Clinical Outcomes (2892–2897)

Session Type: ACR Concurrent Abstract Session

Session Time: 4:30PM-6:00PM

Background/Purpose: Psychosis, one of the rarer neuropsychiatric (NP) events in lupus patients, features in both the ACR and Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE. Our objective was to determine, in a multi-ethnic/racial, prospective SLE inception cohort, the frequency, attribution, clinical and autoantibody associations with lupus psychosis and the outcome as assessed by physicians and patients.

Methods: A prospective study of new onset SLE patients was performed by an international network of 32 academic centers in 11 countries. Patients were evaluated at enrollment and annually for up to 17 years. Data were collected at each assessment on 19 NP events including psychosis, as per the ACR case definitions for NPSLE. Pre-defined decision rules were used to attribute the events to SLE and non-SLE causes. Demographic features, medications, SLE disease activity index-2000 (SLEDAI-2K), SLICC/ACR damage index (SDI) and SF-36 mental (MCS) and physical (PCS) component summary scores were also recorded. Plasma lupus anticoagulant (LAC), serum IgG anti-cardiolipin, anti-β₂ glycoprotein-I, anti-ribosomal P (anti-P) and anti-NR2 glutamate receptor antibodies were measured. Descriptive statistics, time to event analysis and linear regressions were used as appropriate and multivariable models included demographic, clinical and serological variables.

Results: Of 1,826 SLE patients, 88.8% were female, 48.8% Caucasian. The mean±SD age was 35.1±13.3 years, disease duration 5.6±4.2 months and follow-up 7.4±4.5 years. There were 31 psychotic events in 28/1,826 (1.53%) patients and most patients [(26/28; 93%)] had a single event. In the majority of patients [25/28; (89%)] and events [28/31; (90%)] psychosis was attributed to SLE, usually within 3 years of SLE diagnosis. Concurrent therapies included corticosteroids 23/28 (82.1%) with a mean (SD) prednisone dose of 21.9 (14.9) mg/day, immunosuppressants 17/28 (60.7%), biologics 1/28 (3.6%), antipsychotic drugs 19/28 (67.9%) and antidepressants 11/28 (39.3%). In multivariable analyses, positive associations [hazard ratio and 95% confidence interval [HR (95%CI)] with lupus psychosis were prior SLE NP events [3.59, (1.16, 11.14), male sex [3.0, (1.20, 7.50)], younger age at SLE diagnosis [(per 10 years younger), 1.45 (1.01, 2.07)] and African ancestry [4.59 (1.79, 11.76)]. There was no association with SLE disease activity, organ damage or autoantibodies. Patients with psychosis had significantly lower concurrent SF-36 summary scores compared to patients without NP events (MCS: 38.9±13.3 vs. 48.9±10.7; PCS: 38.9±11.0 vs. 44.1±10.9; p<0.001). By physician assessment 80% of psychotic events resolved by the second annual assessment following onset. For these patients there was a concurrent clinically significant improvement in both MCS (45.5±14.1) and PCS scores (43.2±10.9).

Conclusion: Psychosis is an infrequent but important manifestation of NPSLE. It occurs early after SLE onset, is usually mono-phasic and has a significant negative impact on health status. As determined by patient and physician report, the outcome is favorable for most patients.

Disclosure: J. G. Hanly, None; Q. Li, None; L. Su, None; M. Urowitz, None; C. Gordon, None; S. C. Bae, None; J. Romero-Díaz, None; J. Sanchez-Guerrero, None; S. Bernatsky, None; A. E. Clarke, None; D. J. Wallace, None; D. A. Isenberg, None; A. Rahman, None; J. T. Merrill, None; P. R. Fortin, None; D. D. Gladman, None; I. N. Bruce, None; M. Petri, None; E. M. Ginzler, None; M. Dooley, None; K. Steinsson, None; R. Ramsey-Goldman, None; A. A. Zoma, None; S. Manzi, None; O. Nived, None; A. Jönsen, None; M. A. Khamashta, None; G. S. Alarcón, None; R. F. van Vollenhoven, None; C. Aranow, None; M. Mackay, None; G. Ruiz-Irastorza, None; M. Ramos-Casals, None; S. S. Lim, None; M. Inanc, None; K. C. Kalunian, None; S. Jacobsen, None; C. A. Peschken, None; D. L. Kamen, None; A. Askanase, None; C. Theriault, None; V. Farewell, None.

To cite this abstract in AMA style:

Hanly JG, Li Q, Su L, Urowitz M, Gordon C, Bae SC, Romero-Díaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley M, Steinsson K, Ramsey-Goldman R, Zoma AA, Manzi S, Nived O, Jönsen A, Khamashta MA, Alarcón GS, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Ramos-Casals M, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Theriault C, Farewell V. Psychosis in Systemic Lupus Erythematosus: Results from an International, Inception Cohort Study [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/psychosis-in-systemic-lupus-erythematosus-results-from-an-international-inception-cohort-study/. Accessed .

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