Glucocorticoid use is a predictor of organ damage in systemic lupus erythematosus in the Asia Pacific region, however knowledge on the impacts of  other treatments is lacking, an Australian systematic review has found.

The Melbourne researchers say there are multiple studies describing the high prevalence and high disease activity of systemic lupus erythematosus (SLE) in the region, but literature on the predictors of organ damage is limited.

Their review included 38 studies involving 17,480 patients published between 1999 and 2022, of which 22 reported organ damage at enrolment and 19 reported damage accrual, as measured by the Systemic Lupus International Collaborating Clinic/American College of Rheumatology Damage Index.

Organ damage at enrolment mostly involved the musculoskeletal, renal, neuropsychiatric and skin domains, while damage accrual was most common in musculoskeletal, renal, neuropsychiatric, pulmonary, and ocular domains.

Most studies were cohort (84%) and cross-sectional studies (16%).

Writing in Arthritis Care & Research [link here], the authors from Monash Health said that their systematic review showed overall predictors of organ damage in Asia Pacific were similar to other regions.

Three of five studies reporting age at enrolment demonstrated a positive association between older age and organ damage at study enrolment. Older age at enrolment was also associated with damage accrual in three of six studies.

Two of six studies assessing disease duration reported a greater risk of organ damage at study enrolment in patients with a longer duration of disease.

The effect of disease duration on damage accrual was assessed in five studies; two of which reported a positive association.

The researchers also found glucocorticoid use a modifiable risk factor, with four of five studies reporting a positive association between glucocorticoid use and organ damage at study enrolment. Further, five of six studies reported an association between glucocorticoids and damage accrual.

When it came to protective factors, the review reinforced the known benefit of hydroxychloroquine against lupus-related organ damage in other regions, with two of three studies finding that patients using the drug had less organ damage.

Higher C3 level and bisphosphonate use also appeared to be protective, although further investigation was required as few studies had reported this finding and the finding had not been reported in other regions, the researchers noted.

The researchers said organ damage was not associated with azathioprine use, as reported in two studies, or mycophenolate use, as reported in one study, and cyclophosphamide use was not a predictor in a cohort of lupus nephritis patients.

However, they stressed that due to few studies on the topic, the impact of immunosuppressives and biological therapies needed further investigation.

They also reported predictors less widely studied in other regions, including Indian ethnicity, discoid lesions, and elevated Charlson comorbidity index score for organ damage scores at enrolment, and body mass index, metabolic syndrome, lack of remission, and major flares, for damage accrual. These required further attention, they said.

“With regard to predictors of SLE-related organ damage, we found significant overlap between our findings and previous literature from Europe and North America,” wrote the authors, which included Melbourne nephrologist Dr Arushi Ramnarain and leading rheumatologist Professor Eric Morand.

“These commonly reported factors include age, disease duration, disease activity, organ damage at study enrolment, anti-phospholipid syndrome, renal or central nervous system disease as well as use of glucocorticoids.”

They continued: “Apart from glucocorticoids, knowledge regarding the impact of other treatments in the Asia Pacific region, including immunosuppression and biological agents, is lacking.

“In international studies, the use of belimumab in addition to standard therapy has shown promising results, with lower rates of organ damage and accrual. This knowledge gap in the Asia Pacific region needs to be addressed to further understand and minimise treatment-related damage in this cohort.”

One author declared receiving funding from pharmaceutical companies and two authors were employees of GSK at the time of the study.