Clinical Experience of Sirolimus Regarding Efficacy and Safety in Systemic Lupus Erythematosus

Per Eriksson, Philip Wallin, Christopher Sjöwall, Per Eriksson, Philip Wallin, Christopher Sjöwall

Abstract

New treatment options constitute unmet needs for patients diagnosed with systemic lupus erythematosus (SLE). Inhibition of the mammalian target of rapamycin (mTOR) pathway by sirolimus, a drug approved and in clinical use to prevent transplant rejection, has shown promising effects in lupus animal models as well as in patients with both antiphospholipid syndrome and SLE. Sirolimus inhibits antigen-induced T cell proliferation and increases the number of circulating regulatory T cells. Recently, sirolimus was tested in an open label phase 1/2 trial, including 43 patients with active SLE, resistant or intolerant to conventional medications. The results were encouraging showing a progressive improvement, including mucocutaneous and musculoskeletal manifestations. At our university unit, we have more than 16 years' experience of sirolimus as treatment for non-renal manifestations of SLE. Herein, we retrospectively evaluated data on tolerance, dosage, affected organ systems, disease activity measures, corticosteroid reduction, concomitant immunosuppressive therapies, and patient-reported outcome measures (PROMs) such as pain intensity, fatigue, well-being and quality-of-life (QoL) in 27 Caucasian patients with mildly active SLE. Musculoskeletal manifestation was the main reason for sirolimus treatment followed by skin involvement and leukocytopenia. Mean time on sirolimus was 47.1 (range 2-140) months. Decreasing global disease activity was observed, as measured by the clinical SLE disease activity index-2000, with a mean reduction of 2.5 points (range -10 to 0) and a corresponding mean reduction of the physician's global assessment (0-4) of 0.64 (range -2 to 0). The mean daily dose of corticosteroids (prednisolone) was reduced by 3.3 mg (-12.5 to 0). Non-significant trends toward improvements of QoL and pain intensity were found. Serious side-effects were not seen during sirolimus treatment, but early withdrawal due to nausea (n = 4) and non-serious infections (n = 2) appeared. This observational study, including longtime real-life use of sirolimus in SLE, is the largest to date and it essentially confirms the results of the recent phase 1/2 trial. Our data indicate that sirolimus is efficient in patients with musculoskeletal SLE manifestations, particularly arthritis and tendinitis. Further randomized controlled trials evaluating the potential benefits of sirolimus in SLE are warranted, but should aim to enroll patients with shorter disease duration, less accrued damage, and more diverse ethnicities.

Keywords: arthritis; musculoskeletal pain; quality-of-life; sirolimus; systemic lupus erythematosus; tendinitis.

Figures

FIGURE 1
FIGURE 1
(A–D) Longitudinal laboratory efficacy data at the first 12 visits of the 21 cases that passed the 3-month evaluation visit; (A) C-reactive protein, (B) erythrocyte sedimentation rate, (C) complement protein 3, and (D) complement protein 4. ∗p < 0.05, ∗∗p < 0.01, and ∗∗∗p < 0.005.
FIGURE 2
FIGURE 2
(A–D) Differences in global disease activity between start/initiation of sirolimus therapy with regard to (A) clinical SLEDAI-2K, and (B) physician’s global assessment (PGA). (C) Illustrates the reduction of PGA scores with regard to type of musculoskeletal manifestation. (D) Demonstrates the correlation between reduction of daily corticosteroid dose and the exposure of sirolimus in months. ∗p < 0.05.
FIGURE 3
FIGURE 3
(A–F) Longitudinal laboratory safety data at the first 12 visits of the 27 cases; (A) hemoglobin, (B) white blood cell count, (C) neutrophil count, (D) lymphocyte count, (E) platelet count, and (F) plasma creatinine. ∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.005.

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