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Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

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Keeling SO1,2, Alabdurubalnabi Z3,4, Avina-Zubieta A3,4, Barr S3,4, Bergeron L3,4, Bernatsky S3,4, Bourre-Tessier J3,4, Clarke A3,4, Baril-Dionne A3,4, Dutz J3,4, Ensworth S3,4, Fifi-Mah A3,4, Fortin PR3,4, Gladman DD3,4, Haaland D3,4, Hanly JG3,4, Hiraki LT3,4, Hussein S3,4, Legault K3,4, Levy D3,4, Lim L3,4, Matsos M3,4, McDonald EG3,4, Medina-Rosas J3,4, Pardo Pardi J3,4, Peschken C3,4, Pineau C3,4, Pope J3,4, Rader T3,4, Reynolds J3,4, Silverman E3,4, Tselios K3,4, Suitner M3,4, Urowitz M3,4, Touma Z3,4, Vinet E3,4, Santesso N3,4. J Rheumatol. 2018 Oct;45(10):1426-1439. doi: 10.3899/jrheum.171459. Epub 2018 Sep 1.

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1 From the Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Canadian Arthritis Patient Alliance; Division of Rheumatology, Department of Medicine, McGill University; Division of Rheumatology, Department of Medicine, Université de Montréal, Montreal; Division of Rheumatology, Department of Medicine, Université Laval, Quebec City, Quebec; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario; Division of Rheumatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia; Division of Rheumatology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario; Division of Rheumatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; General Internal Medicine, McGill University Health Centre, McGill University, Montreal, Quebec; Cochrane Musculoskeletal Group, University of Ottawa, Ottawa; Division of Rheumatology, Department of Medicine, Western University, London, Ontario; Canadian Agency for Drugs and Technologies in Health, Ottawa; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton; Centre for Practice-changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario. Stephanie.keeling@ualberta.ca.

2 S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, Department of Medicine, University of Alberta; Z. Alabdurubalnabi, MBBS, ABIM, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; A. Avina-Zubieta, MD, MSc, PhD, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; S. Barr, MD, MSc, FRCPC, Associate Professor, University of Calgary; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, McGill University; J. Bourre-Tessier, MD, MSc, FRCPC, Associate Clinical Professor, Université de Montréal; A. Clarke, MD, MSc, FRCPC, Professor of Medicine, Cumming School of Medicine, University of Calgary; A. Baril-Dionne, MD, Internal Medicine Resident, Université de Montréal; J. Dutz, MD, FRCPC, Professor of Medicine, University of British Columbia; S. Ensworth, MD FRCPC, Clinical Assistant Professor, University of British Columbia; A. Fifi-Mah, MD, FRCPC, Clinical Assistant Professor, University of Calgary; P.R. Fortin, MD, FRCPC, Professor of Medicine, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto; D. Haaland, MD, MSc, FRCPC, Assistant Clinical Professor, McMaster University; J.G. Hanly, MD, FRCPC, Professor of Medicine, Dalhousie University; L.T. Hiraki, MD, FRCPC, ScD, Assistant Professor, University of Toronto; S. Hussein, MD, Internal Medicine Resident, Université de Montréal; K. Legault, MD, MSc, FRCPC, Assistant Professor, McMaster University; D. Levy, MD, MSc, FRCPC, Associate Professor, University of Toronto; L. Lim, MBBS, MRCPCH, FRCPC, PhD, Assistant Professor, University of Manitoba; M. Matsos, MD, FRCPC, Associate Professor, McMaster University; E.G. McDonald, MD, FRCPC, Assistant Professor, McGill University; J. Pardo Pardi, Co-Managing Editor, Cochrane Musculoskeletal Group, Centre for Practice-changing Research, Ottawa Hospital Research Institute; C. Peschken, MD, FRCPC, Associate Professor, University of Manitoba; C. Pineau, MD, FRPCP, Associate Professor, McGill University; J. Pope, MD, FRCP(C), Professor of Medicine, Western University; T. Rader, MLIS, Canadian Agency for Drugs and Technologies in Health; J. Reynolds, MD, FRCPC, Clinical Assistant Professor, University of British Columbia; E. Silverman, MD, FRCPC, Professor of Pediatrics, University of Toronto; K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto; M. Suitner, MD, Internal Medicine Resident, Université de Montréal; M. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto; Z. Touma, MD, PhD, Assistant Professor, University of Toronto; E. Vinet, MD, PhD, Assistant Professor, McGill University; N. Santesso, RD, PhD, Assistant Professor, McMaster University. Louise Bergeron and Dr. Jorge Medina-Rosas died before the manuscript was completed. Stephanie.keeling@ualberta.ca.

3 From the Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta; Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, British Columbia; Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Canadian Arthritis Patient Alliance; Division of Rheumatology, Department of Medicine, McGill University; Division of Rheumatology, Department of Medicine, Université de Montréal, Montreal; Division of Rheumatology, Department of Medicine, Université Laval, Quebec City, Quebec; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, Ontario; Division of Rheumatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia; Division of Rheumatology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario; Division of Rheumatology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; General Internal Medicine, McGill University Health Centre, McGill University, Montreal, Quebec; Cochrane Musculoskeletal Group, University of Ottawa, Ottawa; Division of Rheumatology, Department of Medicine, Western University, London, Ontario; Canadian Agency for Drugs and Technologies in Health, Ottawa; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton; Centre for Practice-changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario.

4 S.O. Keeling, MD, MSc, FRCP(C), Division of Rheumatology, Department of Medicine, University of Alberta; Z. Alabdurubalnabi, MBBS, ABIM, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; A. Avina-Zubieta, MD, MSc, PhD, FRCPC, Division of Rheumatology, Department of Medicine, University of British Columbia; S. Barr, MD, MSc, FRCPC, Associate Professor, University of Calgary; S. Bernatsky, MD, PhD, FRCPC, Professor of Medicine, McGill University; J. Bourre-Tessier, MD, MSc, FRCPC, Associate Clinical Professor, Université de Montréal; A. Clarke, MD, MSc, FRCPC, Professor of Medicine, Cumming School of Medicine, University of Calgary; A. Baril-Dionne, MD, Internal Medicine Resident, Université de Montréal; J. Dutz, MD, FRCPC, Professor of Medicine, University of British Columbia; S. Ensworth, MD FRCPC, Clinical Assistant Professor, University of British Columbia; A. Fifi-Mah, MD, FRCPC, Clinical Assistant Professor, University of Calgary; P.R. Fortin, MD, FRCPC, Professor of Medicine, Université Laval; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto; D. Haaland, MD, MSc, FRCPC, Assistant Clinical Professor, McMaster University; J.G. Hanly, MD, FRCPC, Professor of Medicine, Dalhousie University; L.T. Hiraki, MD, FRCPC, ScD, Assistant Professor, University of Toronto; S. Hussein, MD, Internal Medicine Resident, Université de Montréal; K. Legault, MD, MSc, FRCPC, Assistant Professor, McMaster University; D. Levy, MD, MSc, FRCPC, Associate Professor, University of Toronto; L. Lim, MBBS, MRCPCH, FRCPC, PhD, Assistant Professor, University of Manitoba; M. Matsos, MD, FRCPC, Associate Professor, McMaster University; E.G. McDonald, MD, FRCPC, Assistant Professor, McGill University; J. Pardo Pardi, Co-Managing Editor, Cochrane Musculoskeletal Group, Centre for Practice-changing Research, Ottawa Hospital Research Institute; C. Peschken, MD, FRCPC, Associate Professor, University of Manitoba; C. Pineau, MD, FRPCP, Associate Professor, McGill University; J. Pope, MD, FRCP(C), Professor of Medicine, Western University; T. Rader, MLIS, Canadian Agency for Drugs and Technologies in Health; J. Reynolds, MD, FRCPC, Clinical Assistant Professor, University of British Columbia; E. Silverman, MD, FRCPC, Professor of Pediatrics, University of Toronto; K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto; M. Suitner, MD, Internal Medicine Resident, Université de Montréal; M. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto; Z. Touma, MD, PhD, Assistant Professor, University of Toronto; E. Vinet, MD, PhD, Assistant Professor, McGill University; N. Santesso, RD, PhD, Assistant Professor, McMaster University. Louise Bergeron and Dr. Jorge Medina-Rosas died before the manuscript was completed.

Abstract

OBJECTIVE: To develop recommendations for the assessment of people with systemic lupus erythematosus (SLE) in Canada.

METHODS: Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. The Canadian SLE Working Group (panel of Canadian rheumatologists and a patient representative from Canadian Arthritis Patient Alliance) was created. Questions for recommendation development were identified based on the results of a previous survey of SLE practice patterns of members of the Canadian Rheumatology Association. Systematic literature reviews of randomized trials and observational studies were conducted. Evidence to Decision tables were prepared and presented to the panel at 2 face-to-face meetings and online.

RESULTS: There are 15 recommendations for assessing and monitoring SLE, with varying applicability to adult and pediatric patients. Three recommendations focus on diagnosis, disease activity, and damage assessment, suggesting the use of a validated disease activity score per visit and annual damage score. Strong recommendations were made for cardiovascular risk assessment and measuring anti-Ro and anti-La antibodies in the peripartum period and conditional recommendations for osteoporosis and osteonecrosis. Two conditional recommendations were made for peripartum assessments, 1 for cervical cancer screening and 2 for hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination.

CONCLUSION: These are considered the first guidelines using the GRADE method for the monitoring of SLE. Existing evidence is largely of low to moderate quality, resulting in more conditional than strong recommendations. Additional rigorous studies and special attention to pediatric SLE populations and patient preferences are needed.