Practice Variations in the Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus in Canada

Stephanie O Keeling; Asvina Bissonauth; Sasha Bernatsky; Ben Vandermeer; Paul R Fortin; Dafna D Gladman; Christine Peschken; Murray B Urowitz

doi:10.3899/jrheum.171307

Practice Variations in the Diagnosis, Monitoring, and Treatment of Systemic Lupus Erythematosus in Canada

J Rheumatol. 2018 Oct;45(10):1440-1447. doi: 10.3899/jrheum.171307. Epub 2018 Aug 1.

Authors

Stephanie O Keeling^{1

2}, Asvina Bissonauth^{3

4}, Sasha Bernatsky^{3

4}, Ben Vandermeer^{3

4}, Paul R Fortin^{3

4}, Dafna D Gladman^{3

4}, Christine Peschken^{3

4}, Murray B Urowitz^{3

4}

Affiliations

¹ From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada. Stephanie.keeling@ualberta.ca.
² S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto. Stephanie.keeling@ualberta.ca.
³ From the Division of Rheumatology, University of Alberta, Edmonton, Alberta; Division of Rheumatology, McGill University, Montreal, Quebec; Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta; Division of Rheumatology, CHU de Québec, Université Laval, Quebec City, Quebec; Division of Rheumatology, University of Toronto, Toronto, Ontario; Division of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.
⁴ S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, University of Alberta; A. Bissonauth, MRes, Research Coordinator, Division of Rheumatology, University of Alberta; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, Division of Rheumatology, McGill University; B. Vandermeer, MSc, Biostatistician, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta; P.R. Fortin, MD, FRCPC, Professor of Medicine, Division of Rheumatology, CHU de Québec, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, Division of Rheumatology, University of Toronto; C. Peschken, MD, FRCPC, Associate Professor of Medicine, Division of Rheumatology, University of Manitoba; M.B. Urowitz, MD, FRCPC, Division of Rheumatology, University of Toronto.

PMID: 30068762
DOI: 10.3899/jrheum.171307

Abstract

Objective: To evaluate the diagnosis, monitoring, and treatment of systemic lupus erythematosus (SLE) in Canada.

Methods: A 63-question electronic survey was developed with the Canadian Rheumatology Association and others. Descriptive analyses of responses were performed.

Results: Survey respondents (n = 175) reported varying practices in the diagnosis, monitoring, and treatment of SLE. Performance of laboratory investigations for diagnosis and monitoring varied, with 78% of responders performing them at least every 6 months. Validated measures of SLE disease activity and damage were not commonly used. Most common first-line agents besides steroids for induction therapy for class III or IV lupus nephritis included intravenous cyclophosphamide and mycophenolate mofetil. Antimalarial use was common, with 96% of respondents using these in active skin disease. Over 60% of respondents indicated that 80-100% of their patients were taking antimalarials, while another 25% indicated they used these drugs in up to 80% of their patients. There were 71% of responders who reported completing frequent (6-12 mos) ophthalmology screening in patients taking antimalarials. Biologics were infrequently used. Responders were more likely to stop azathioprine and chloroquine than hydroxychloroquine in pregnant patients with SLE. Other aspects of routine care including vaccination and cardiovascular risk management varied considerably. The majority (80%) agreed that a dedicated multidisciplinary care team would improve SLE care.

Conclusion: Considerable practice variation in SLE management was noted. This may help inform future recommendations for the diagnosis, monitoring, and treatment of SLE in Canada.

Keywords: DIAGNOSIS; DISEASE ACTIVITY; MONITORING; PHYSICIAN PRACTICE PATTERNS; SYSTEMIC LUPUS ERYTHEMATOSUS; TREATMENT.

Publication types

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

MeSH terms

Adult
Antimalarials / therapeutic use
Antirheumatic Agents / therapeutic use
Biological Products / therapeutic use
Canada
Cardiovascular Diseases / diagnosis
Female
Glucocorticoids / therapeutic use
Humans
Hydroxychloroquine / therapeutic use
Lupus Erythematosus, Systemic / diagnosis*
Lupus Erythematosus, Systemic / drug therapy*
Lupus Nephritis / drug therapy
Male
Patient Care Team
Practice Patterns, Physicians'*
Pregnancy
Public Health Practice*
Rheumatologists / psychology*
Risk Assessment
Skin Diseases / drug therapy
Surveys and Questionnaires
Vaccination

Substances

Antimalarials
Antirheumatic Agents
Biological Products
Glucocorticoids
Hydroxychloroquine