The last issue of Rheumatic Disease Clinics of North America to cover systemic lupus erythematosus (SLE) was published in February 2010. In only the last four years, there have been dramatic changes in our understanding of the immunology, genetic/epigenetic associations, and identification of new targets for therapy in this multifaceted disease. We are very excited to have invited a superb group of authors to present articles detailing cutting-edge advances in these areas.
The initial series of articles cover the review of interactions between environmental exposures on disease susceptibility and presentation by Kamen, the update on lupus genetics and gene/environment interactions by James, and the discussion by Gonzalez and coworkers of the contribution of race and ethnicity to disease prevalence, expression, and response to therapy.
Advances in our knowledge of pathophysiologic processes have clearly informed our understanding of organ-specific disease features and long-term risk of irreversible damage. The article by Kirchhof and Dutz provides an excellent review of the immunologic processes and triggers contributing to the cutaneous manifestations of SLE and implications for new therapeutic modalities. McMahon and Skaggs review the lupus-specific risks and biomarkers for accelerated atherosclerosis, which contribute to the high burden of morbidity and mortality among lupus patients. Tessier Cloutier and colleagues discuss the unique cancer risk profile in patients with lupus, including new data on incidence, prevalence, and contributing factors.
Each of these previous articles may suggest new approaches to therapy. At the same time, there have been exciting advances in the therapeutic armamentarium for SLE. The first new medication for SLE approved by the FDA occurred in 2011; Askenase and coworkers summarize the clinical trials data for Benlysta (belimumab) and review the postmarketing experience with this biologic agent. Ward provides a critical assessment of the recent clinical trials in lupus nephritis, noting that comparison among studies is hampered by differences in patient populations, outcome measures, and response criteria. Suggestions for remediating these issues are provided in the article by Rovin and colleagues, with recommendations for repeat renal biopsy after therapeutic interventions and potential use of molecular diagnostics to validate noninvasive biomarkers, allowing for personalized therapy. Finally, Choi and coworkers discuss the critical importance of improving enrollment in lupus clinical trials, recommending changes in trial design, and the approach to the patient with SLE.