title: The number of flares patients experience impacts on damage accrual in systemic lupus erythematosus: data from a multiethnic Latin American cohort.
abstract: OBJECTIVE
  To determine the association between the number of flares systemic lupus erythematosus (SLE) patients experience and damage accrual, independently of other known risk factors.
  
  
  METHODS
  SLE patients (34 centres, nine Latin American countries) with a recent diagnosis (≤2 years) and ≥3 evaluations were studied. Disease activity was ascertained with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and damage with the SLICC/ACR Damage Index (SDI). Flare was defined as an increase ≥4 points in the SLEDAI between two study visits. An ambidirectional case- crossover design was used to determine the association between the number of flares and damage accrual.
  
  
  RESULTS
  901 patients were eligible for the study; 500 of them (55.5%) experienced at least one flare, being the mean number of flares 0.9 (SD: 1.0). 574 intervals from 251 patients were included in the case-crossover design since they have case and control intervals, whereas, the remaining patients did not. Their mean age at diagnosis was 27.9 years (SD: 11.1), 213 (84.9%) were women. The mean baseline SDI and SLEDAI were 1.3 (1.3) and 13.6 (8.1), respectively. Other features were comparable to those of the entire sample. After adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (SDI) OR 2.05, 95% CI 1.43 to 2.94, p<0.001 (OR 2.62, 95% CI 1.31 to 5.24, p=0.006 for severe and OR 1.91, 95% CI 1.28 to 2.83, p=0.001 for mild-moderate).
  
  
  CONCLUSIONS
  The number of flares patients experience, regardless of their severity, increases the risk of damage accrual, independently of other known risk factors.
authors: Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Científica del Sur, Lima, Perú
authors: Manuel F
authors: MF
authors: Ugarte-Gil
authors: Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Nacional Mayor de San Marcos, Lima, Perú
authors: Eduardo
authors: E
authors: Acevedo-Vásquez
authors: Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors: Graciela S
authors: GS
authors: Alarcón
authors: Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú. Universidad Nacional Mayor de San Marcos, Lima, Perú
authors: Cesar A
authors: CA
authors: Pastor-Asurza
authors: Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú.
authors: José L
authors: JL
authors: Alfaro-Lozano
authors: Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú.
authors: Jorge M
authors: JM
authors: Cucho-Venegas
authors: Universidad Nacional Mayor de San Marcos, Lima, Perú Servicio de Reumatología, Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú
authors: Maria I
authors: MI
authors: Segami
authors: Universidad Nacional de Rosario, Rosario, Argentina.
authors: Daniel
authors: D
authors: Wojdyla
authors: Servicio de Reumatología, Hospital Italiano and Fundación Dr. Pedro M. Catoggio para el Progreso de la Reumatología, Buenos Aires, Argentina.
authors: Enrique R
authors: ER
authors: Soriano
authors: Division of Rheumatology, Emory University School of Medicine, Atlanta, USA.
authors: Cristina
authors: C
authors: Drenkard
authors: Hospital das Clinicas de Porto Alegre, Universidade Federal do, Rio Grande do Sul, Brazil.
authors: João Carlos
authors: JC
authors: Brenol
authors: Rheumatology Unit, Medical Faculty, Goiás Federal University, Goiânia, Brazil.
authors: Ana Carolina
authors: AC
authors: de Oliveira e Silva Montandon
authors: Divisao de Reumatologia, Faculdade de Ciencias Medicas, Universidade Estadual da Campinas, Campinas, Brazil.
authors: Lilian T Lavras
authors: LT
authors: Costallat
authors: Department of Clinical Immunology and Rheumatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
authors: Loreto
authors: L
authors: Massardo
authors: Universidad CES, Medellín, Colombia.
authors: José F
authors: JF
authors: Molina-Restrepo
authors: Servicio de Reumatología, Centro de Investigaciones Médico Quirúrgicas (CIMEQ), La Habana, Cuba.
authors: Marlene
authors: M
authors: Guibert-Toledano
authors: Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, México D.F., México.
authors: Luis H
authors: LH
authors: Silveira
authors: Centro Médico ABC, Mexico D.F., Mexico.
authors: Mary Carmen
authors: MC
authors: Amigo
authors: Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico D.F., Mexico.
authors: Leonor A
authors: LA
authors: Barile-Fabris
authors: Servicio de Reumatología, Centro Nacional de Enfermedades Reumáticas, Hospital Universitario de Caracas, Caracas, Venezuela.
authors: Rosa
authors: R
authors: Chacón-Díaz
authors: Hospital Central de San Cristóbal, San Cristobal, Venezuela.
authors: Maria H
authors: MH
authors: Esteva-Spinetti
authors: Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA Department of Autoimmune Diseases, Institut Clinic de Medicina I Dermatologia, Hospital Clinic, Barcelona, Catalonia, Spain.
authors: Guillermo J
authors: GJ
authors: Pons-Estel
authors: Department of Epidemiology, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors: Gerald
authors: G
authors: McGwin
authors: Hospital Provincial de Rosario, Rosario, Argentina.
authors: Bernardo A
authors: BA
authors: Pons-Estel
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use; D044383:Black People; D016022:Case-Control Studies; D015331:Cohort Studies; D018592:Cross-Over Studies; D018450:Disease Progression; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007199:Indians, South American; D007843:Latin America; D008180:Lupus Erythematosus, Systemic / Q000188:drug therapy / Q000503:physiopathology*; D008297:Male; D012720:Severity of Illness Index; D013997:Time Factors; D044465:White People; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D000962:Antimalarials; D007166:Immunosuppressive Agents
keywords: Disease Activity; Outcomes Research; Systemic Lupus Erythematosus