Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

Stephanie O Keeling; Zainab Alabdurubalnabi; Antonio Avina-Zubieta; Susan Barr; Louise Bergeron; Sasha Bernatsky; Josiane Bourre-Tessier; Ann Clarke; Alexandra Baril-Dionne; Jan Dutz; Stephanie Ensworth; Aurore Fifi-Mah; Paul R Fortin; Dafna D Gladman; Derek Haaland; John G Hanly; Linda T Hiraki; Sara Hussein; Kimberly Legault; Deborah Levy; Lily Lim; Mark Matsos; Emily G McDonald; Jorge Medina-Rosas; Jordi Pardo Pardi; Christine Peschken; Christian Pineau; Janet Pope; Tamara Rader; Jen Reynolds; Earl Silverman; Konstantinos Tselios; Manon Suitner; Murray Urowitz; Zahi Touma; Evelyne Vinet; Nancy Santesso

doi:10.3899/jrheum.171459

Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

J Rheumatol. 2018 Oct;45(10):1426-1439. doi: 10.3899/jrheum.171459. Epub 2018 Sep 1.

Authors

Stephanie O Keeling^{1

2}, Zainab Alabdurubalnabi^{3

4}, Antonio Avina-Zubieta^{3

4}, Susan Barr^{3

4}, Louise Bergeron^{3

4}, Sasha Bernatsky^{3

4}, Josiane Bourre-Tessier^{3

4}, Ann Clarke^{3

4}, Alexandra Baril-Dionne^{3

4}, Jan Dutz^{3

4}, Stephanie Ensworth^{3

4}, Aurore Fifi-Mah^{3

4}, Paul R Fortin^{3

4}, Dafna D Gladman^{3

4}, Derek Haaland^{3

4}, John G Hanly^{3

4}, Linda T Hiraki^{3

4}, Sara Hussein^{3

4}, Kimberly Legault^{3

4}, Deborah Levy^{3

4}, Lily Lim^{3

4}, Mark Matsos^{3

4}, Emily G McDonald^{3

4}, Jorge Medina-Rosas^{3

4}, Jordi Pardo Pardi^{3

4}, Christine Peschken^{3

4}, Christian Pineau^{3

4}, Janet Pope^{3

4}, Tamara Rader^{3

4}, Jen Reynolds^{3

4}, Earl Silverman^{3

4}, Konstantinos Tselios^{3

4}, Manon Suitner^{3

4}, Murray Urowitz^{3

4}, Zahi Touma^{3

4}, Evelyne Vinet^{3

4}, Nancy Santesso^{3

4}

Affiliations

¹ From the Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Canadian Arthritis Patient Alliance; Division of Rheumatology, Department of Medicine, McGill University; Division of Rheumatology, Department of Medicine, Université de Montréal, Montreal; Division of Rheumatology, Department of Medicine, Université Laval, Quebec City, Quebec; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario; Division of Rheumatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia; Division of Rheumatology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario; Division of Rheumatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; General Internal Medicine, McGill University Health Centre, McGill University, Montreal, Quebec; Cochrane Musculoskeletal Group, University of Ottawa, Ottawa; Division of Rheumatology, Department of Medicine, Western University, London, Ontario; Canadian Agency for Drugs and Technologies in Health, Ottawa; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton; Centre for Practice-changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario. Stephanie.keeling@ualberta.ca.
² S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, Department of Medicine, University of Alberta; Z. Alabdurubalnabi, MBBS, ABIM, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; A. Avina-Zubieta, MD, MSc, PhD, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; S. Barr, MD, MSc, FRCPC, Associate Professor, University of Calgary; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, McGill University; J. Bourre-Tessier, MD, MSc, FRCPC, Associate Clinical Professor, Université de Montréal; A. Clarke, MD, MSc, FRCPC, Professor of Medicine, Cumming School of Medicine, University of Calgary; A. Baril-Dionne, MD, Internal Medicine Resident, Université de Montréal; J. Dutz, MD, FRCPC, Professor of Medicine, University of British Columbia; S. Ensworth, MD FRCPC, Clinical Assistant Professor, University of British Columbia; A. Fifi-Mah, MD, FRCPC, Clinical Assistant Professor, University of Calgary; P.R. Fortin, MD, FRCPC, Professor of Medicine, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto; D. Haaland, MD, MSc, FRCPC, Assistant Clinical Professor, McMaster University; J.G. Hanly, MD, FRCPC, Professor of Medicine, Dalhousie University; L.T. Hiraki, MD, FRCPC, ScD, Assistant Professor, University of Toronto; S. Hussein, MD, Internal Medicine Resident, Université de Montréal; K. Legault, MD, MSc, FRCPC, Assistant Professor, McMaster University; D. Levy, MD, MSc, FRCPC, Associate Professor, University of Toronto; L. Lim, MBBS, MRCPCH, FRCPC, PhD, Assistant Professor, University of Manitoba; M. Matsos, MD, FRCPC, Associate Professor, McMaster University; E.G. McDonald, MD, FRCPC, Assistant Professor, McGill University; J. Pardo Pardi, Co-Managing Editor, Cochrane Musculoskeletal Group, Centre for Practice-changing Research, Ottawa Hospital Research Institute; C. Peschken, MD, FRCPC, Associate Professor, University of Manitoba; C. Pineau, MD, FRPCP, Associate Professor, McGill University; J. Pope, MD, FRCP(C), Professor of Medicine, Western University; T. Rader, MLIS, Canadian Agency for Drugs and Technologies in Health; J. Reynolds, MD, FRCPC, Clinical Assistant Professor, University of British Columbia; E. Silverman, MD, FRCPC, Professor of Pediatrics, University of Toronto; K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto; M. Suitner, MD, Internal Medicine Resident, Université de Montréal; M. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto; Z. Touma, MD, PhD, Assistant Professor, University of Toronto; E. Vinet, MD, PhD, Assistant Professor, McGill University; N. Santesso, RD, PhD, Assistant Professor, McMaster University. Louise Bergeron and Dr. Jorge Medina-Rosas died before the manuscript was completed. Stephanie.keeling@ualberta.ca.
³ From the Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Canadian Arthritis Patient Alliance; Division of Rheumatology, Department of Medicine, McGill University; Division of Rheumatology, Department of Medicine, Université de Montréal, Montreal; Division of Rheumatology, Department of Medicine, Université Laval, Quebec City, Quebec; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario; Division of Rheumatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia; Division of Rheumatology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario; Division of Rheumatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; General Internal Medicine, McGill University Health Centre, McGill University, Montreal, Quebec; Cochrane Musculoskeletal Group, University of Ottawa, Ottawa; Division of Rheumatology, Department of Medicine, Western University, London, Ontario; Canadian Agency for Drugs and Technologies in Health, Ottawa; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton; Centre for Practice-changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario.
⁴ S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, Department of Medicine, University of Alberta; Z. Alabdurubalnabi, MBBS, ABIM, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; A. Avina-Zubieta, MD, MSc, PhD, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; S. Barr, MD, MSc, FRCPC, Associate Professor, University of Calgary; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, McGill University; J. Bourre-Tessier, MD, MSc, FRCPC, Associate Clinical Professor, Université de Montréal; A. Clarke, MD, MSc, FRCPC, Professor of Medicine, Cumming School of Medicine, University of Calgary; A. Baril-Dionne, MD, Internal Medicine Resident, Université de Montréal; J. Dutz, MD, FRCPC, Professor of Medicine, University of British Columbia; S. Ensworth, MD FRCPC, Clinical Assistant Professor, University of British Columbia; A. Fifi-Mah, MD, FRCPC, Clinical Assistant Professor, University of Calgary; P.R. Fortin, MD, FRCPC, Professor of Medicine, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto; D. Haaland, MD, MSc, FRCPC, Assistant Clinical Professor, McMaster University; J.G. Hanly, MD, FRCPC, Professor of Medicine, Dalhousie University; L.T. Hiraki, MD, FRCPC, ScD, Assistant Professor, University of Toronto; S. Hussein, MD, Internal Medicine Resident, Université de Montréal; K. Legault, MD, MSc, FRCPC, Assistant Professor, McMaster University; D. Levy, MD, MSc, FRCPC, Associate Professor, University of Toronto; L. Lim, MBBS, MRCPCH, FRCPC, PhD, Assistant Professor, University of Manitoba; M. Matsos, MD, FRCPC, Associate Professor, McMaster University; E.G. McDonald, MD, FRCPC, Assistant Professor, McGill University; J. Pardo Pardi, Co-Managing Editor, Cochrane Musculoskeletal Group, Centre for Practice-changing Research, Ottawa Hospital Research Institute; C. Peschken, MD, FRCPC, Associate Professor, University of Manitoba; C. Pineau, MD, FRPCP, Associate Professor, McGill University; J. Pope, MD, FRCP(C), Professor of Medicine, Western University; T. Rader, MLIS, Canadian Agency for Drugs and Technologies in Health; J. Reynolds, MD, FRCPC, Clinical Assistant Professor, University of British Columbia; E. Silverman, MD, FRCPC, Professor of Pediatrics, University of Toronto; K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto; M. Suitner, MD, Internal Medicine Resident, Université de Montréal; M. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto; Z. Touma, MD, PhD, Assistant Professor, University of Toronto; E. Vinet, MD, PhD, Assistant Professor, McGill University; N. Santesso, RD, PhD, Assistant Professor, McMaster University. Louise Bergeron and Dr. Jorge Medina-Rosas died before the manuscript was completed.

PMID: 30173152
DOI: 10.3899/jrheum.171459

Abstract

Objective: To develop recommendations for the assessment of people with systemic lupus erythematosus (SLE) 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 a patient representative from Canadian Arthritis Patient Alliance) was created. Questions for recommendation development were identified based on the results of a previous survey of SLE practice patterns of members of the Canadian Rheumatology Association. Systematic literature reviews of randomized trials and observational studies were conducted. Evidence to Decision tables were prepared and presented to the panel at 2 face-to-face meetings and online.

Results: There are 15 recommendations for assessing and monitoring SLE, with varying applicability to adult and pediatric patients. Three recommendations focus on diagnosis, disease activity, and damage assessment, suggesting the use of a validated disease activity score per visit and annual damage score. Strong recommendations were made for cardiovascular risk assessment and measuring anti-Ro and anti-La antibodies in the peripartum period and conditional recommendations for osteoporosis and osteonecrosis. Two conditional recommendations were made for peripartum assessments, 1 for cervical cancer screening and 2 for hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination.

Conclusion: These are considered the first guidelines using the GRADE method for the monitoring of SLE. Existing evidence is largely of low to moderate quality, resulting in more conditional than strong recommendations. Additional rigorous studies and special attention to pediatric SLE populations and patient preferences are needed.

Keywords: ASSESSMENT; COMORBIDITIES; GRADE; MONITORING; RECOMMENDATIONS; SYSTEMIC LUPUS ERYTHEMATOSUS.

Publication types

Practice Guideline
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Canada
Cardiovascular Diseases / diagnosis
Cardiovascular Diseases / etiology
Child
Female
Health Personnel
Health Planning Guidelines*
Hepatitis C / diagnosis
Hepatitis C / etiology
Humans
Infections / diagnosis
Infections / etiology
Lupus Erythematosus, Systemic / complications
Lupus Erythematosus, Systemic / diagnosis*
Lupus Erythematosus, Systemic / therapy*
Male
Mass Screening*
Osteonecrosis / diagnosis
Osteonecrosis / etiology
Osteoporosis / diagnosis
Osteoporosis / etiology
Peripartum Period / blood
Pregnancy
Rheumatologists
Risk Assessment
Severity of Illness Index
Systematic Reviews as Topic
Uterine Cervical Neoplasms / diagnosis
Uterine Cervical Neoplasms / etiology
Vaccination

Grants and funding

CIHR/Canada