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Assessment of patients with systemic lupus erythematosus and the use of lupus disease activity indices

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The assessment of disease activity in systemic lupus erythematosus (SLE) is a task faced by clinicians in every day care, but it is also required for clinical research and in randomised controlled trials. It is crucial to distinguish disease activity from infection, chronic damage and co-morbid disease. Over the past 20 years, many indices have been developed to objectively measure lupus disease activity and several of these have been validated. The most widely used indices are the British Isles Lupus Assessment Group (BILAG) index, the European Consensus Lupus Activity Measurement (ECLAM), the Systemic Lupus Activity Measure (SLAM), the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Lupus Activity Index (LAI). All these indices have been validated and have excellent reliability, validity and responsiveness to change. In addition to the assessment of disease activity, the evaluation of damage using the validated SLICC/ACR damage index and health-related quality of life is advised for clinical research.

Section snippets

What should physicians assess, and why?

Most physicians are aware of the 11 revised classification criteria for SLE of the American College of Rheumatology (ACR).1 (Table 1) A patient has to have four or more of these criteria to be classified as having SLE. These classification criteria are not diagnostic criteria; they were developed for research purposes to provide some attempt at standardisation for entry into clinical trials or outcome studies. The criteria do not have to be present simultaneously but can be cumulative over a

The disease activity indices

There is no gold standard for measuring disease activity in lupus and the physicians' visual analogue scale is not reliable in practice.19, 20 Although the physician's opinion is often considered the ‘gold standard’ for the evaluation of disease activity, it is evident that there is bias based on personal experience and different opinions on the relative merits of disease activity in different systems.20 Thus, an experience-based evaluation of activity cannot allow comparisons of data because

Assessment of damage

The treatment of lupus has improved. Fewer patients are dying early in their disease than 20–30 years ago.67 However, more patients are dying of the complications of lupus and the co-morbidities associated with lupus later in life, such as premature coronary and cerebrovascular disease67, 68. These complications are also causing increasing morbidity in lupus patients, at a time when the disease activity has usually been controlled by immunosuppressive therapy.

A group of investigators interested

Assessment of quality of life

From the patient's perspective it is important to consider health status/quality of life when assessing patients with lupus. To date, generic health status questionnaires have been used to formally assess the health-related quality of life of patients with lupus. The Short Form 36 (SF-36) has been most widely used.47 It covers eight domains assessing physical function, social function, role limitation due to physical or emotional factors, mental health, vitality, pain and general health

Summary

The assessment of a lupus patient is complex and requires a holistic approach. Disease activity, damage, health-related quality of life and the prevention of complications, including drug side effects, should be included in the assessment. With the development of new drugs and the need of controlled randomised studies, the evaluation of disease activity has become of paramount importance to select candidate patients for trials and to assess drug efficacy. Assessment of disease activity is also

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