Addressing Clinical Challenges in the Management of SLE With Dr Petri

“My view of life is unorthodox, meaning that I think classification criteria ought to be used for diagnosis too, and our slight classification criteria are not limited to research,” explained Michelle Petri, MD, in discussing how such criteria can be as useful in diagnosis as in observational studies, clinical trials, and patient recruitment.

Dr Petri is a professor at Johns Hopkins University School of Medicine in Baltimore, Maryland.

Between the Systemic Lupus Collaborating Clinics (SLICC), and European League Against Rheumatism (EULAR)—listed as SLICC 2012 and EULAR/ACR in an updated sensitivity and specificity study comparing these SLE classification rules and Revised ACR-11—Dr Petri believes all 3 classification rules are useful.

In evaluating the challenges associated with conventional nonspecific immunosuppressive agents, she discussed different trials, including a new phase-3 trial of anifrolumab (TULIP-1 and 2).

“TULIP 1 didn’t meet its primary endpoint, which was SRI [SLE Responder Index], so on TULIP 2 a different primary endpoint was chosen called BICLA [BILAG-based Combined Lupus Assessment]. By the way, SRI and BICLA include the 3 same activity measures,” she explained.

Dr Petri went on to explain further testing models, some of which offered some positive results in the use of Janus kinase (JAK) inhibitors for patients with lupus, but waiting for the following phases is key to see if the results remain encouraging.

“Here is my favorite trial,” Dr Petri said of the Low-Dose IL-2 in SLE Improves SRI-4 Response study. “Why is this my favorite? Because I think this could be groundbreaking, the same way checkpoint inhibitors have changed things in oncology. Because the purpose of low-dose Interleukin-2 is to help the T-regulatory cells to police the immune system in, should we say, a natural way. To get away from immunosuppression so that we don’t have to think about infections and later risk of cancer. In this study, even at week 12 you saw there was benefit. And excellent benefit at week 24. We need to see this from multiple companies now,” explained Dr Petri.

Dr Petri moved on to various supplements patients tend to experiment with that clinicians need to study in order to understand in order to explain the various complications to patients, such as an increase of tacrolimus levels, further aggravation of the disease, and inflammation that can result from supplements such as turmeric and cannabidiol (CBD).

Dr Petri emphasized the importance of a focus on patient-related outcomes and symptoms. She explained the 2 different types of patients: Type 1 is a group of patients with classic signs and SLE symptoms, while Type 2 is noninflammatory. Type 1 patients have a clear-cut relationship to autoimmunity, but Type 2 patients do not respond to immunosuppression, and experience symptoms such as fatigue, diffuse pain, sleep disturbance, anxiety, depression, and brain fog.

Dr Petri further discussed the symptoms and possible treatments for Type 1 and 2 patients, including aids for chronic fatigue. After ruling out anemia, hypothyroidism, and obstructive sleep apnea, she recommends aerobic exercise. For cases of anxiety and depression, Dr Petri recommends psychiatry and psychology, if her patients are reluctant to speak with her. Treating the underlying depression is also vital in treating brain fog in lupus patients, she concluded.

--Angelique Platas

Petri M. Addressing clinical challenges in the management of systemic lupus erythematosus. Talk presented at: Interdisciplinary Autoimmune Summit. April 17, 2021. Virtual.