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Fall (Volume 28, Number 3)

Executive Summary: CRA Recommendations for the Assessment and Monitoring of SLE

By Stephanie Keeling, MD, MSc, FRCPC, on behalf of the Canadian SLE Working Group

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As an initiative of the CRA, the Canadian Systemic Lupus Erythematosus (SLE) Working Group developed 15 recommendations for the assessment and monitoring of people with SLE in Canada. These recommendations are based on the results of a CRA survey of SLE practice patterns and are the first guidelines for SLE assessment using the GRADE method (Grading of Recommendations, Assessment, Development and Evaluation). The recommendations include best practice statements which include a complete history, physical and lab examination for all pediatric and adult lupus patients and careful coordination of care in the peripartum period. To view the guidelines, please visit rheum.ca/resources/publications/ or jrheum.org/content/early/2018/08/27/jrheum.171459.

Recommendation

Strength of recommendation, Quality of evidence

(1) We recommend that all adult patients suspected of SLE be referred to an SLE specialist, most often a rheumatologist, to confirm diagnosis and be involved in ongoing care.

Strong, Moderate quality

(2) For adult and pediatric patients with SLE, we suggest assessing disease activity with a validated instrument of disease activity during baseline and follow-up visits.

Conditional, Low quality

(3) For adult and pediatric patients with SLE, we suggest assessing disease damage annually with a validated measure.

Conditional, Low quality

(4) For adults with SLE, we recommend that indicators of obesity, smoking status, arterial hypertension, diabetes, and dyslipidemia be measured upon diagnosis of SLE, and be reassessed periodically according to current recommendations in the general population and be used to inform the cardiovascular (CV) risk assessment.

Strong, High quality

(5) For adults with SLE, we suggest that carotid ultrasonography not be a part of the CV risk assessment, except in highly selected cases where expertise is available.

Conditional, Low quality

(6) For all adult patients with SLE, we suggest assessing for risk of osteoporosis and fractures every 1 to 3 years using a detailed history and focused physical examination, and measuring bone mineral density in patients with other risk factors according to recommendations in the general population.

Conditional, Low quality

(7) For all adults with SLE, we suggest screening for 25-hydroxy vitamin D levels as part of the assessment for risk of osteoporosis and fractures.

Conditional, Low quality

(8) For patients who have suspected clinical symptoms of osteonecrosis, we suggest radiographs as the initial imaging modality rather than MRI or bone scan with SPECT, according to recommendations in the general population.

Conditional, Low quality

(9) For women with SLE, we recommend that anti-Ro and anti-La antibodies be measured prior to pregnancy or during the first trimester.

Strong, Low quality

(10) For pregnant women with SLE, we suggest that uterine and umbilical Doppler studies be performed in the second or third trimester, or at the time of a suspected flare.

Conditional, Low quality

(11) For women with prior or active lupus nephritis who are pregnant, we suggest measuring serum creatinine and urine protein to creatinine ratio every 4-6 weeks, or more frequently if clinically indicated. We suggest blood pressure and urinalysis be measured prior to pregnancy and every 4-6 weeks until 28 weeks, every 1–2 weeks until 36 weeks, and then weekly until delivery

Conditional, Low quality

(12) For all female adult patients with SLE who are or have been sexually active, regardless of sexual orientation, we suggest annual cervical cancer screening rather than screening every 3 years, at least up to the age of 69.

Conditional, Low quality

(13) We recommend that adults and children with SLE receive an annual inactivated influenza vaccination in a single dose.

Strong, Moderate quality

(14) For adult and pediatric patients with a diagnosis of SLE and high-risk behaviors for hepatitis B virus acquisition, we recommend screening for HbsAg and repeating according to recommendations for the general population. For patients being considered for immunomodulatory therapy, we suggest screening before starting treatment.

Conditional, Low quality

(15) For adults and pediatric patients with a diagnosis of SLE and high-risk behaviours for hepatitis C virus (HCV) acquisition, we recommend screening for HCV and repeating according to recommendations in the general population. For all other adult and pediatric patients with a diagnosis of SLE, we suggest screening for HCV and repeating according to recommendations in the general population.

Conditional, Low quality

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