New research encourages early recognition and steroid-sparing treatment.

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can affect organs like the kidneys, lungs, brain, and heart. A new study at Vanderbilt University Medical Center investigated SLE’s association with resistant hypertension (RHTN) by (1) comparing RHTN incidence in patients with and without SLE; and (2) examining the association of RHTN with clinical characteristics and mortality.

Researchers found that patients with SLE had twice the rate of RHTN than control subjects and that SLE patients with RHTN had worse clinical outcomes.

Principal investigator Cecilia Chung, M.D., a Vanderbilt rheumatologist, sees value in identifying patients who are at a higher risk for developing resistant hypertension. “If we know who is most vulnerable,” she said, “we may gain multiple advantages conferred by early monitoring and intervention.”

Findings Describe At-risk Population

In this retrospective study, researchers reviewed the records of 1,044 SLE patients and 5,241 control subjects. RHTN was defined as blood pressure that could not be controlled even while taking three anti-hypertensive medications or which required four or more medications to obtain control.

Researchers found that nearly twice as many of the SLE patients had RHTN compared to control patients (10.2 percent versus 5.3 percent). Other key findings include:

• Both incidence and prevalence of the RHTN were higher among SLE patients.

• Among SLE patients, RHTN was associated with a nearly three-fold increase in mortality.

• RHTN in patients with SLE was associated with black race, lower renal function, hypercholesterolemia, and increased inflammatory markers.

Corticosteroids: Treatment or Exacerbation?

Investigators found significantly higher inflammatory markers among SLE patients and, not surprisingly, found that SLE patients who developed RHTN were much more likely to have taken prednisone or a calcineurin inhibitor prior to the RHTN diagnosis. Thus, this study also underscores the need to try to limit the dose and length of use of corticosteroids as much as possible, Chung said.

“We need to be sensitive to trying alternative means of controlling inflammation in these patients.”

“We have seen in lupus patients an overuse of corticosteroids, and now we are seeing evidence of their strong associations with RHTN. We need to be sensitive to trying alternative means of controlling inflammation in these patients.”

Early Interventions to Delay or Prevent RHTN

Chung sees many patients with lupus who have accelerated atherosclerosis, which is associated with uncontrolled hypertension. “I hope that if we act early to address patient-controlled lifestyle factors we can help control the disease of RHTN and its comorbidities,” she says. Chung also emphasizes the value of using electronic health records as a way to provide rich longitudinal information from a real-world clinical setting for research.

Vanderbilt medical student Jocelyn Gandelman was first author on the study, and she and her colleagues are moving forward to look at variability in blood pressure and body mass index in these same cohorts.

“RHTN is a story that plays out over time, not a snapshot. We can’t have a full understanding until we know when problems start and how they progress,” Chung says.

About the Expert

Cecilia P. Chung, M.D.

Cecilia Chung, M.D., M.P.H., is an associate professor of medicine at Vanderbilt University Medical Center. Her research focuses on pharmacoepidemiology and pharmacogenetics of drugs used in rheumatology.