Treat-to-target in systemic lupus erythematosus: recommendations from an international task force.

The principle of treating-to-target has been successfully applied to many diseases outside rheumatology and more recently to rheumatoid arthritis. Identifying appropriate therapeutic targets and pursuing these systematically has led to improved care for patients with these diseases and useful guidance for healthcare providers and administrators. Thus, an initiative to evaluate possible therapeutic targets and develop treat-to-target guidance was believed to be highly appropriate in the management of systemic lupus erythematosus (SLE) patients as well. Specialists in rheumatology, nephrology, dermatology, internal medicine and clinical immunology, and a patient representative, contributed to this initiative. The majority convened on three occasions in 2012-2013. Twelve topics of critical importance were identified and a systematic literature review was performed. The results were condensed and reformulated as recommendations, discussed, modified and voted upon. The finalised bullet points were analysed for degree of agreement among the task force. The Oxford Centre level of evidence (LoE, corresponding to the research questions) and grade of recommendation (GoR) were determined for each recommendation. The 12 systematic literature searches and their summaries led to 11 recommendations. Prominent features of these recommendations are targeting remission, preventing damage and improving quality of life. LoE and GoR of the recommendations were variable but agreement was >0.9 in each case. An extensive research agenda was identified, and four overarching principles were also agreed upon. Treat-to-target-in-SLE (T2T/SLE) recommendations were developed by a large task force of multispecialty experts and a patient representative. It is anticipated that 'treating-to-target' can and will be applicable to the care of patients with SLE

Opportunities and challenges in rheumatology research in Central Europe

The Central European Congress of Rheumatology (CECR) has been organized by seven Central European countries: Austria, Croatia, Czech Republic, Hungary, Poland, Slovakia, and Slovenia. These countries have lots of similarities, but also differences, with respect to rheumatology research. In this paper, based on questionnaires, we wish to demonstrate achievements and difficulties in rheumatology research performed in our region

A Combination of CD28 (rs1980422) and IRF5 (rs10488631) Polymorphisms Is Associated with Seropositivity in Rheumatoid Arthritis: A Case Control Study.

INTRODUCTION:The aim of the study was to analyse genetic architecture of RA by utilizing multiparametric statistical methods such as linear discriminant analysis (LDA) and redundancy analysis (RDA). METHODS:A total of 1393 volunteers, 499 patients with RA and 894 healthy controls were included in the study. The presence of shared epitope (SE) in HLA-DRB1 and 11 SNPs (PTPN22 C/T (rs2476601), STAT4 G/T (rs7574865), CTLA4 A/G (rs3087243), TRAF1/C5 A/G (rs3761847), IRF5 T/C (rs10488631), TNFAIP3 C/T (rs5029937), AFF3 A/T (rs11676922), PADI4 C/T (rs2240340), CD28 T/C (rs1980422), CSK G/A (rs34933034) and FCGR3A A/C (rs396991), rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPA) and clinical status was analysed using the LDA and RDA. RESULTS:HLA-DRB1, PTPN22, STAT4, IRF5 and PADI4 significantly discriminated between RA patients and healthy controls in LDA. The correlation between RA diagnosis and the explanatory variables in the model was 0.328 (Trace = 0.107; F = 13.715; P = 0.0002). The risk variants of IRF5 and CD28 genes were found to be common determinants for seropositivity in RDA, while positivity of RF alone was associated with the CTLA4 risk variant in heterozygous form. The correlation between serologic status and genetic determinants on the 1st ordinal axis was 0.468, and 0.145 on the 2nd one (Trace = 0.179; F = 6.135; P = 0.001). The risk alleles in AFF3 gene together with the presence of ACPA were associated with higher clinical severity of RA. CONCLUSIONS:The association among multiple risk variants related to T cell receptor signalling with seropositivity may play an important role in distinct clinical phenotypes of RA. Our study demonstrates that multiparametric analyses represent a powerful tool for investigation of mutual relationships of potential risk factors in complex diseases such as RA

SNPs associated with seropositivity in RA.

<p>Redundancy discrimination analysis plot showing that IRF5, CD28 and CTLA4 are associated with seropositivity in RA patients. RF+–rheumatoid factor positive RA patients; RF-–rheumatoid factor negative RA patients; ACPA+–anti-citrullinated peptides antibodies positive RA patients; ACPA-–anti-citrullinated peptides antibodies negative RA patients; SE (0,1,2)—number of shared epitope coding alleles in HLA-DRB1 gene (✧); IRF5 (CC, CT, TT)—genotypes in IRF5 gene (C risk allele) (▷); CD28 (CC, CT, TT)–genotypes in CD28 gene (C risk allele) (◁); CTLA4 (AG, GG, AA)–genotypes in CTLA4 gene (G risk allele) (◊). Diagram reading clue: Symbols are genetic factors. Large bold symbols represent genotypes significantly influencing the presence of RF and ACPA. Small empty symbols represent other genotypes of selected genes. Direction of arrow indicates which serologic status is associated with the genetic parameters and the length of the arrow indicates the magnitude of the association.</p

Factors associated with clinical severity in RA.

<p>Redundancy analysis plot showing that risk alleles in AFF3 gene, together with ACPA positivity are associated with higher clinical severity of RA. ACPA—anti-citrullinated peptides antibodies (□); <i>AFF3</i> (TT, AT, AA)–genotypes in <i>AFF3</i> gene (T risk allele) (▽). Diagram reading clue: Symbols are genetic and serologic factors. Large bold symbols represent genotypes and antibody presence significantly influencing the clinical parameters of disease severity (DAS28, CRP, ESR, TJC, SJC, HAQ-DI). Small empty symbols represent other factors and genotypes of selected genes. Direction of arrow indicates which of the clinical factors are associated with the genetic and serologic parameters and the length of the arrow indicates the magnitude of the association.</p

The genetic discrimination of RA patients and controls.

<p>Linear discrimination analysis diagram shows that shared epitope and single nucleotide polymorphisms in PTPN22, STAT4, IRF5 and PADI4 genes significantly discriminated between RA patients and healthy controls. RA—RA patients; C—control group; SE (0,1,2)—number of SE coding allele in HLA-DRB1 gene (✧); IRF5 (CC, CT, TT)—genotypes in IRF5 gene (C risk allele) (◁); PADI4 (TT, CT, CC)–genotypes in PADI4 gene (T risk allele) (▽); PTPN22 (CC, CT, TT)–genotypes in PTPN22 gene (A risk allele) (△); STAT4 (GG, GT, TT)–genotypes in STAT4 gene (T risk allele) (☐). Diagram reading clue: Small circles represent individual cases. Large grey circles—centroids—represent subject groups (RA patients and controls). Symbols are genetic factors. Large bold symbols represent genotypes significantly influencing the distribution of subjects. Small empty symbols represent other genotypes of selected genes. The closer to the group centroid the gene symbol lies, the stronger is its impact on the classification of subjects to particular group.</p

Basic demographics of RA cases and healthy controls.

<p>Basic demographics of RA cases and healthy controls.</p

Treat-to-target in systemic lupus erythematosus: recommendations from an international task force.

The principle of treating-to-target has been successfully applied to many diseases outside rheumatology and more recently to rheumatoid arthritis. Identifying appropriate therapeutic targets and pursuing these systematically has led to improved care for patients with these diseases and useful guidance for healthcare providers and administrators. Thus, an initiative to evaluate possible therapeutic targets and develop treat-to-target guidance was believed to be highly appropriate in the management of systemic lupus erythematosus (SLE) patients as well. Specialists in rheumatology, nephrology, dermatology, internal medicine and clinical immunology, and a patient representative, contributed to this initiative. The majority convened on three occasions in 2012-2013. Twelve topics of critical importance were identified and a systematic literature review was performed. The results were condensed and reformulated as recommendations, discussed, modified and voted upon. The finalised bullet points were analysed for degree of agreement among the task force. The Oxford Centre level of evidence (LoE, corresponding to the research questions) and grade of recommendation (GoR) were determined for each recommendation. The 12 systematic literature searches and their summaries led to 11 recommendations. Prominent features of these recommendations are targeting remission, preventing damage and improving quality of life. LoE and GoR of the recommendations were variable but agreement was >0.9 in each case. An extensive research agenda was identified, and four overarching principles were also agreed upon. Treat-to-target-in-SLE (T2T/SLE) recommendations were developed by a large task force of multispecialty experts and a patient representative. It is anticipated that 'treating-to-target' can and will be applicable to the care of patients with SLE

A framework for remission in SLE: consensus findings from a large international task force on definitions of remission in SLE (DORIS)

Treat-to-target recommendations have identified 'remission' as a target in systemic lupus erythematosus (SLE), but recognise that there is no universally accepted definition for this. Therefore, we initiated a process to achieve consensus on potential definitions for remission in SLE