Navigating Neuropsychiatric Lupus: Improving Diagnosis and Treatment

Announcer:
You’re listening to Living Rheum on ReachMD. On this episode, Dr. Alexandra Legge will discuss recent advances and future considerations for the diagnosis and management of neuropsychiatric lupus. Not only is Dr. Legge an Assistant Professor of Rheumatology at Dalhousie University’s Department of Medicine, but she’s also the Director of the Dalhousie University Lupus Clinic. Let’s hear from Dr. Legge now.  

Dr. Legge:
The American College of Rheumatology in 1999 published nomenclature and case definitions for 19 different neuropsychiatric lupus syndromes, 12 of those affecting the central nervous system and seven affecting the peripheral nervous system. And with those case definitions, they provided a detailed definition for each syndrome as well as a list of exclusions or alternative etiologies and a list of associations or other contributing factors to each syndrome to help clinicians with determining whether a particular neuropsychiatric syndrome might be attributable to lupus versus an alternative cause. And really, those original nomenclature and case definitions that were published by the ACR in 1999 are still the most widely used framework for thinking about neuropsychiatric lupus today.

What we’ve realized about those case definitions over time is that while they do have high sensitivity for picking up neuropsychiatric manifestations of lupus, they tend to have very low specificity. So a lot of the research efforts that have come in more recent years have been focused on creating attribution models that could help clinicians to more accurately differentiate between neuropsychiatric manifestations of lupus versus other potential causes of neuropsychiatric symptoms.

There have been many significant advances in our understanding of neuropsychiatric lupus in recent years. I think we’ve done a very good job in recent years of characterizing neuropsychiatric events in lupus patients. We know that neuropsychiatric events are extremely common. They occur in about half of patients with systemic lupus. And we now have data to suggest that roughly one-third of those neuropsychiatric events are directly attributable to lupus itself. We know that these events are associated with very high economic costs from some recent data from the SLICC Inception Cohort, and we also know that these neuropsychiatric events are associated with really significant morbidity and increased mortality compared to lupus patients who don’t experience neuropsychiatric disease. So there really is a very high unmet need among patients with systemic lupus in terms of better addressing these neuropsychiatric events through accurate diagnosis as well as more effective treatments.

Some of the upcoming research that holds a lot of promise in terms of improving the care of patients with neuropsychiatric lupus would include some of the work that’s being done to identify more accurate biomarkers of neuropsychiatric disease. So that includes advanced neuroimaging biomarkers as well as laboratory biomarkers, such as autoantibodies and other cytokines in the serum and cerebrospinal fluid of patients with neuropsychiatric lupus. And so having validated biomarkers that can help us more accurately identify when neuropsychiatric symptoms are directly attributable to lupus versus other causes will really be a game-changer for clinicians in terms of being able to more accurately diagnose neuropsychiatric lupus and therefore being able to initiate appropriate therapy in a timely fashion.

Another important area for future research is accumulating more high-quality evidence for the treatment of neuropsychiatric lupus. Currently, patients with severe neuropsychiatric disease are excluded from clinical trials, and this has really limited the quality of the evidence available to us to inform our treatment of patients with neuropsychiatric manifestations. So future research will really need to focus on including patients with neuropsychiatric disease in clinical trials to better inform our management.

Announcer:
That was Dr. Alexandra Legge talking about the diagnosis and management of neuropsychiatric lupus. To access this and other episodes in our series, visit Living Rheum on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!