Systemic Lupus Erythematosus: Adding Value to Our Patients with the Art of Medicine

VBCR - October 2013, Volume 2, No 5 - VBCR Perspectives

By John Kolstoe, MD
Dr Kolstoe is in private practice at Kolstoe Rheumatology: Musculoskeletal Medicine,
East Lansing, MI, and an editorial board member of Value-Based Care in Rheumatology

The August 2013 issue of Value-­Based Care in Rheumatology devoted 3 articles to systemic lupus erythematosus (SLE). Two of the articles pertained to refining the clinical “state” of SLE through newer laboratory criteria (“New Biomarkers and Biomarker Panels Show Promise for Diagnosing and Monitoring Patients with Lupus”)1 or through available clinical criteria (“New Diagnostic Algorithm for SLE Can Facilitate Early Treatment, Improve Outcomes”)2; the third article reviewed the effect of treatment with vitamin D (“Increasing Vitamin D Intake in Patients with Lupus Provides Modest Benefit”).3 All 3 articles will assist the clinician’s decision on how and when to treat the individual patient with SLE.

The science of medicine yields models to explain the nature of disease. Science helps us to ask pertinent questions of the individual patient. The answers to these questions guide a diagnosis to determine the risks versus benefits related to symptoms versus treatments for the individual patient.

The “art of medicine” is the application of the “science of medicine” onto the unique individual patient. The art of medicine (or the “cycle of clinical care”) consists of translating an individual’s symptoms into a diagnosis, which, in turn, leads to treating the patient, and then repeating the process as needed or as tolerated. The art of medicine provides value-based care to the patient, guided by models derived from the science of medicine.

SLE has long been noted for its pleomorphism, making it difficult to conform to an exclusive diagnostic and treatment regimen. The American Rheumatism Association in the 1960s recognized this complexity and sponsored a committee to develop criteria for the classification of SLE to form a more uniform patient population to study. The articles discussing new biomarkers and a new algorithm for SLE continue these efforts to fine-tune the science of medicine.1,2

Science has confirmed the polygenetic background allowing for multiple autoimmune disorders “overlapping” in a patient with SLE and/or in the patient’s family members. Genome-wide studies have identified more than 30 loci seen with a high enough frequency to be tied to autoimmunity. Few of these loci confer enough risk to explain the full manifestation of autoimmunity, but the more loci (approximately 4+), the greater the risk.

From a probabilistic point of view, the number of ways 4 items can be chosen from 30 different items is 27,405 (ie, 30 × 29 × 28 × 27 ÷ 4 × 3 × 2 = 27,405). This would be the number of possible genetic combinations that could underlie a clinical presentation of SLE. This explains the uniqueness of the individual patient, and why no 2 individual patients are likely to be “identical” in their disease manifestation, let alone in their response to a therapy.

Even the immune systems of so-called identical twins evolve somatic mutations (genetic and epigenetic) to respond to new environmental exposures.4,5 This explains the lack of uniform disease manifestations in identical twin pairs. Individuals are unique, therefore rarely “fulfilling criteria.” Using the cycle of clinical care, our “diagnosis” is close enough to the model disorder (ie, SLE) to warrant either treatment or further observation.

We do not treat groups of patients, we treat individuals. Two of the articles mentioned above address constellations of laboratory values or clinical features—criteria that could refine “treatment thresholds” for the individual patient. The vitamin D study used a group of patients who fulfill SLE criteria to see if that group derives benefit from such treatment. Devising these criteria to help determine “how sick” a patient is can help to define the value of a therapeutic medicine needed in value-based care.

References

  1. Frei R. New biomarkers and biomarker panels show promise for diagnosing and monitoring patients with lupus. Value-Based Care in Rheumatology. August 2013;2(4):1.
  2. Frei R. New diagnostic algorithm for SLE can facilitate early treatment, improve outcomes. Value-Based Care in Rheumatology. August 2013;2(4):15.
  3. In The Literature. Increasing vitamin D intake in patients with lupus provides modest benefit. Value-Based Care in Rheumatology. August 2013;2(4):14.
  4. Taylor KE, Chung SA, Graham RR, et al. Risk alleles for systemic lupus erythematosus in a large case-­control collection and associations with clinical subphenotypes. PLoS Genet. 2011;7:e1001311.
  5. Anaya JM, Gómez L, Castiblanco J. Is there a common genetic basis for autoimmune diseases? Clin Dev Immunol. 2006;13:185-195.
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