Several flare score systems adequately assessed the majority of flares in patients with systemic lupus erythematosus, according to findings published in Arthritis Care and Research.
“This was a major international effort involving over 40 clinicians, assessing close to 1000 'paper patient' profiles in an attempt to help resolve a thorny issue of how we can accurately capture the assessment of flare in patients with lupus,” David Isenberg, MD, of University College London, told Healio Rheumatology. “Although not providing a fool proof method it was a big step down the path and a very important extension of a 'real patient' assessment exercise undertaken several years earlier by the SLICC group which could only study 16 patients.”
To assess how accurately these systems assessed flares, and to evaluate the level of agreement of flare severity across multiple systems, the researchers conducted a patient-paper exercise with 988 individual cases of systemic lupus erythematosus. Three physicians individually assessed all 988 lupus case histories, and came to complete agreement on persistent disease activity in 46% of cases. Those 451 cases served as a reference standard for the study’s second part.
The researchers randomly distributed the 451 cases to 18 pairs of physicians who assessed them using three instruments — the British Isles Lupus Assessment Group (BILAG) 2004 index, the Safety of Estrogens in Lupus Erythematosus National Assessment (SELENA) flare index and the revised SELENA flare index. The SELENA systems are based on, but not directly linked to, the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) index.
According to the researchers, the initial, three-physician assessment largely matched the level of flare severity of three indices, with 67% agreement for BILAG 2004, 72% agreement for the SELENA index and 70% agreement for the revised SELENA index. The weighted kappa coefficients for each instrument were 0.82 for BILAG 2004, 0.59 for the SELENA index and 0.74 for the revised SELENA index.
The researchers added that although they were “encouraged” by the results, more work is needed to address the problem of accurately assessing flares in patients with lupus.
“Three flare activity indices derived from somewhat different philosophies have shown promise in their utilization as means of distinguishing mild from moderate and severe lupus,” Isenberg said. “However, distinguishing the severe and the moderate cases remains challenging.” – by Jason Laday
Disclosure: The researchers report grant funding from the American College of Rheumatology and EULAR.