Treatment target in newly diagnosed systemic lupus erythematosus: The association of lupus low disease activity state and remission with lower accrual of early damage

Objectives: To compare the effect of achievement and maintenance of lupus low disease activity state (LLDAS) and clinical remission (CR) in preventing early damage accrual in patients with systemic lupus erythematosus (SLE). Methods: In a monocentric cohort of 116 newly diagnosed SLE patients, LLDAS and CR achievement at 6 months (T1) after treatment initiation and their maintenance over the next 12 months were assessed. Early damage was recorded after 18 months of follow-up (T2) using the SLICC/damage index. Uni- and multivariate analysis were performed to evaluate the association of LLDAS and CR with early damage. Results: LLDAS was significantly more attained than CR both at T1 (42.2% vs. 21.6% of patients, p<0.001) and T2 (46.6% vs. 31.9%, p=0.022). Overlap rate between persistent LLDAS and persistent CR was 41.7% (n=15). On multivariate analysis, achievement of CR (OR 0.07, 95%CI 0.01 to 0.59, p=0.015) and LLDAS (OR 0.25, 95%CI 0.06 to 0.99, p=0.049) at T1 were independently associated with lower accrual of early damage. Patients who achieved LLDAS (including CR) at T1 and steadily persisted in this condition until T2 developed significantly less damage compared to those who failed to maintain it during the T1-T2 interval (p=0.003), those who achieved it later than T1 (p<0.001) or those who had never been in this condition (p<0.001). Conclusions: Although CR is recommended as the primary treatment target in SLE, LLDAS represents a valid alternative in the early stage of SLE management. LLDAS and CR maintenance should be targeted to prevent damage.