ReviewSLE diagnosis and treatment: When early is early
Section snippets
Diagnosis and classification of SLE
In clinical practice the diagnosis of SLE is usually made in a patient who has developed a combination of clinical and immunologic features specific to SLE. Of course diseases which can mimic SLE have to be concomitantly ruled out.
Criteria for the classification of SLE were elaborated by the American College of Rheumatology (ACR) firstly in 1971, then revised in 1982, and then again in 1997. Unfortunately, they are not diagnostic; in fact, they cannot be applied to every individual case, since
Timing of SLE diagnosis over years
The lag time between the onset and the diagnosis of SLE reported in major cohort studies was approximately 50 months before 1980 [1] and approximately 25–26 months after 1980 [2].
In our cohort of 487 SLE patients recruited between 1970 and 2008, the mean lag time between the onset and the diagnosis was 59 months in patients diagnosed before 1980, a figure similar to that reported by Wallace in 1981 [2], 28 months in those diagnosed between 1980 and 1989, 15 months in those diagnosed between 1990 and
When does SLE start?
Genetic susceptibility represents a relevant aspect in the pathogenesis of SLE. SLE is a multigenic disease; a combination of genome-wide scanning, family studies, and candidate gene approaches has led to the identification of a series of genes which determine the susceptibility to the disease. They are genes which on the one hand inhibit the clearance of apoptotic cells favouring autoantigen exposure and on the other hand predispose the immune system to an aberrant responsiveness.
In this
How can we identify patients with early SLE?
Of course, to perform tissue biopsies in asymptomatic patients in order to identify the preclinical stage is unethical. What we are currently able to identify in clinical practice are ANA, which are very useful in the diagnostic process; however, we know that only a small percentage of asymptomatic ANA-positive patients will eventually develop SLE, but, unfortunately, we cannot predict which of them.
When aspecific manifestations such as Raynaud's phenomenon or arthralgia occur in association
What is the importance of early diagnosis?
If we look at animal models, which represent suitable models from this point of view due to the possibility of manipulating them before disease occurrence, we can see that all successful interventions are most effective when they are introduced before the development of full-blown clinical lupus [22]. Only a few of them are also effective after the disease has established.
In humans, data on early interventions are very limited. It has been shown that a delay in renal biopsy higher than 24 months
How should we manage patients with early lupus?
The current treatment of early, mild lupus consists of the use of low-dose corticosteroids and antimalarial drugs. However, a number of other interventions have recently been proposed in the early stage of lupus.
Take-home messages
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Early SLE diagnosis is crucial for an early therapeutic intervention which can increase the probability of disease remission and improve patient prognosis.
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Biomarkers which help us to identify SLE patients in an early stage of the disease are urgently needed.
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Antimalarials, vitamin D, statins and vaccination with self peptides are among the best candidates for early therapeutic intervention in SLE
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