Pulse dose steroids in severe pulmonary arterial hypertension secondary to systemic lupus erythematosus

Objective: The pulmonary vascular targeted treatment for systemic lupus erythematosus–associated pulmonary arterial hypertension is similar to other connective tissue disease–associated pulmonary arterial hypertension. In addition, there also appears to be a role for immunosuppression in the overall management. However, the optimal immunosuppressive regimen and what patients will respond to treatments are currently not clearly elucidated given the lack of randomized controlled trials on the subject. Our objective is to highlight the importance of early immunosuppression in systemic lupus erythematosus–associated pulmonary arterial hypertension and the role of pulse dose steroids in management. Methods: This case describes a 23-year-old woman who presented with pulmonary arterial hypertension diagnosed by right heart catheterization with mean pulmonary artery pressure of 74 mmHg, pulmonary capillary wedge pressure of 12 mmHg, and a pulmonary vascular resistance of 1908 dyne s cm−5. Due to the aggressive nature of her disease, she declined despite management with epoprostenol and sildenafil. Because of coexisting systemic lupus erythematosus with hemolytic anemia and worsening pulmonary arterial hypertension, intensive immunosuppressive therapy with pulse dose steroids was initiated. Results: Shortly after initiation of pulse dose steroids and maintenance immunosuppression, she had a dramatic symptomatic and hemodynamic response with a decrease in her pulmonary vascular resistance from 1908 to 136 dyne sec cm−5 and improvement in her mean pulmonary artery pressure from 74 to 27 mmHg on repeat right heart catheterization. Conclusion: Early immunosuppression is important to consider in those with systemic lupus erythematosus–associated pulmonary arterial hypertension. Limited studies are available, but most have focused on the use of cyclophosphamide. Pulse dose steroids may be a potentially less toxic but equally effective manner to aid in the treatment of systemic lupus erythematosus–pulmonary arterial hypertension when intensive immunosuppression is being considered.

Download Full-text

SAT0240 THE PROGNOSIS OF TWO DISTINCT CLINICAL PHENOTYPES OF SLE-PAH

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.4520 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1063.2-1063

Author(s):

J. Wang ◽

Y. Feng ◽

Y. Lei ◽

X. Zhang

Keyword(s):

Systemic Lupus Erythematosus ◽

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Lupus Erythematosus ◽

Right Heart Catheterization ◽

Heart Catheterization ◽

Systemic Lupus ◽

Clinical Phenotypes ◽

Weighted Score ◽

Pulmonary Arterial

Background:Based on the characteristics of systemic lupus erythematosus-associated pulmonary arterial hypertension (SLE-PAH), Sunet alhas put forward a scoring system to distinguish two clinical phenotypes as vasculitic and vasculopathic subtypes[1]. A weighted score ≥2 suggested a vasculitic subtype by combining two factors: The time interval between SLE and PAH diagnosis <2 years and ≥2 years were 1 and 0 point; SLE Disease Activity Index (SLEDAI) >9, 5-9 and <5 were 2, 1, 0 point, respectively. While the vasculitic subtype seemed to have poorer prognosis in Sun’s research, other study has shown controversial result[2].Objectives:To find out the prognosis of two distinct clinical phenotypes of SLE-PAH.Methods:Between 2008 and 2019, a SLE-PAH cohort confirmed by right heart catheterization (RHC) from Guangdong Provincial People’s Hospital was included. Other groups of pulmonary hypertension were excluded. Based on the scoring system, patients were divided into vasculitic (weighted score≥2) and vasculopathic subtypes (weighted score<2). The endpoint was PAH-related mortality. Survival status were confirmed by clinic follow-up data or phone call.Results:A total of 53 SLE-PAH patients were enrolled. The cases of vasculitic and vasculopathic subtype were 14 and 39, respectively. Ten endpoint events occurred. Eight attributed to PAH and the cause could not be traced in two which were still included in study. The pooled 1-, 3-, 5-year survival rates were 85.7%, 78.6%, 65.5% in vasculitic subtype, and 93.9%, 87.5%, 87.5% in vasculopathic subtype, respectively. Kaplan-Meier analysis showed vasculitic subtype tended to have a poorer prognosis than vasculopathic subtype (p=0.16, HR 2.4, 95%CI 0.5-13.8, figure 1).Figure 1.Survival curves for patients with systemic lupus erythematosus-pulmonary arterial hypertension (SLE-PAH) in two distinct subtypes. RHC, Right Heart Catheterization.Conclusion:The prognosis of the two phenotypes of SLE-PAH was statistically indifferent while the vasculitic subtype showed a trend of worse prognosis. Further studies are needed.References:[1]F. Sun, Y. Lei, W. Wu, L. Guo, K. Wang, Z. Chen, W. Xu, X. Wang, T. Li, X. Zhang, S. Ye, Two distinct clinical phenotypes of pulmonary arterial hypertension secondary to systemic lupus erythematosus, Ann Rheum Dis 78(1) (2019) 148-150.[2]J. Qian, M. Li, J. Zhao, Q. Wang, Z. Tian, X. Zeng, Inflammation in SLE-PAH: good news or not?, Ann Rheum Dis (2018).0:1–2. doi:10.1136/annrheumdis-2018-214605Disclosure of Interests:None declared

Download Full-text

Pulmonary Arterial Hypertension in Systemic Lupus Erythematosus: Current Status and Future Direction

Clinical and Developmental Immunology ◽

10.1155/2012/854941 ◽

2012 ◽

Vol 2012 ◽

pp. 1-12 ◽

Cited By ~ 33

Author(s):

Atiya Dhala

Keyword(s):

Systemic Lupus Erythematosus ◽

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Lupus Erythematosus ◽

Connective Tissue Diseases ◽

Anticardiolipin Antibody ◽

Current Status ◽

Systemic Lupus ◽

Right Heart ◽

Pulmonary Arterial

Pulmonary arterial hypertension (PAH) is commonly associated with connective tissue diseases (CTDs) including systemic sclerosis and systemic lupus erythematosus (SLE). The prevalence of PAH in SLE is estimated to be 0.5% to 17.5%. The pathophysiology of PAH involves multiple mechanisms from vasculitis andin-situthrombosis to interstitial pulmonary fibrosis which increases pulmonary vascular resistance, potentially leading to right heart failure. Immune and inflammatory mechanisms may play a significant role in the pathogenesis or progression of PAH in patients with CTDs, establishing a role for anti-inflammatory and immunosuppressive therapies. The leading predictors of PAH in SLE are Raynaud phenomenon, anti-U1RNP antibody, and anticardiolipin antibody positivity. The first-line of diagnostic testing for patients with suspected SLE-associated PAH (SLE-aPAH) involves obtaining a Doppler echocardiogram. Once the diagnosis is confirmed by right heart catheterization, SLE-aPAH patients are generally treated with oxygen, anticoagulants, and vasodilators. Although the prognosis and therapeutic responsiveness of these patients have improved with the addition of intensive immunosuppressive therapies, these treatments are still largely unproven. Recent data put the one-year survival rate for SLE-aPAH patients at 94%. Pregnant women are most at risk of dying due to undiagnosed SLE-aPAH, and screening should be considered essential in this population.

Download Full-text

Pulmonary Arterial Hypertension In A Female Patient With Systemic Lupus Erythematosus

Internal Medicine ◽

10.2478/inmed-2018-0040 ◽

2018 ◽

Vol 15 (5) ◽

pp. 75-81

Author(s):

Cristiana Drăgănescu ◽

Tudor Constantinescu ◽

Oana Enache ◽

Marina Speriatu ◽

Raida Oneaţă ◽

...

Keyword(s):

Systemic Lupus Erythematosus ◽

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Female Patient ◽

Lupus Erythematosus ◽

Rare Complication ◽

Heart Catheterization ◽

Systemic Lupus ◽

Cutaneous Manifestations ◽

Pulmonary Arterial

AbstractIntroduction. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown origin, characterized by multisystemic involvement and a potentially severe evolution. Pulmonary arterial hypertension (PAH) is a rare complication of SLE, with low 5-year survival.Case presentation. We are presenting the case of a female patient, aged 56 years old, diagnosed in 1992 with SLE with cutaneous manifestations (butterfly-shaped erythematous rash), joint manifestations (polyarthritis), serositis manifestations (massive pleuropericarditis), and immunological manifestations (positive anti-dsDNA antibodies, decreased C3), ignored therapeutically for a long time. In 2010 she complained of dyspnea on medium exertion and leg edemas, with marked increase of PAPs by echocardiography. She was diagnosed with severe PAH (confirmed by right heart catheterization) and in the “Marius Nasta” National Institute of Pneumology she started a treatment with an endothelin receptor antagonist (Bosentan) in combination with a prostacyclin receptor agonist (Selexipag). Since 2013 the patient is on oral anticoagulant treatment for permanent atrial fibrillation.In 2015 she was referred back to out clinic as she complained of recurrent episodes of massive ascites with evacuatory paracenteses in amounts of about 6-9L per paracentesis. After excluding other causes, ascites was considered to be secondary to the SLE, and a treatment was initiated with Hydroxychloroquine (HCQ) and pulse therapy with Methylprednisolone, on which the remission of the ascites was achieved during the following months. Currently, the SLE is well controlled without recurrence of ascites on treatment with HCQ and gradual decrease until stopping of cortisone doses, and the PAH is stable.Conclusion. PAH is a rare complication of the SLE, with a complex pathophysiological immune mechanism, for which - together with the specific vasodilator treatment - the increase of immune suppression is recommended.

Download Full-text