Glucocorticoid (GC) withdrawal may be attempted in patients with systemic lupus erythematosus (SLE) in complete remission; however, flare risk during GC discontinuation must be considered. Long-term treatment with hydroxychloroquine and prolonged disease remission are predictors of withdrawal of GC treatment in patients with SLE, according to study results published in Lupus.
Although the withdrawal of GCs is important in the management of patients with SLE, the optimal duration of GC maintenance therapy before safe discontinuation is not clear, with many patients continuing to receive long-term low-dose prednisone despite clinical remission.
The objective of the current study was to assess the outcomes of flare rate in patients with SLE in remission, and to identify disease and treatment characteristics associated with disease flare in patients with SLE following GC withdrawal.
The retrospective study included patients with SLE admitted to the rheumatology unit of University of Campania, Italy, between November 1, 2000, and December 31, 2019. All participants received low-dose GCs, defined as prednisone at a dosage 5 mg/day or lower for at least 1 year.
The study sample included 246 patients, of whom 154 were in clinical remission for 2 years or more during follow-up. A trial of withdrawal of GC treatment was reported in approximately one-third (n=56; 36.3%) of patients with SLE in clinical remission (withdrawal group); 98 (63.6%) patients continued to receive low-dose GCs at a stable dosage of 5 mg/day (maintenance group).
There was no difference in the risk for disease flare between patients in the withdrawal group (n=7/56; 12.5%) and those in the maintenance group (n=10/98; 11.2%; P =.81). Furthermore, there was no difference in damage progression between the groups at the end of follow-up (P =.48).
Disease flares following withdrawal of GCs were more common among patients with serologically active clinically quiescent (SACQ) disease, defined as an at least 1-year period with persistent serologic activity without clinical manifestations (n=6/11 [54%] vs 1/45 [2%], respectively; P <.0001).
Long-term treatment with hydroxychloroquine was associated with a lower risk for disease flares (hazard ratio [HR], 0.84; P =.03) and 5-year lasting remission at GC withdrawal (HR, 0.12; P =.0003). On the other hand, both serologic activity without clinical manifestations (HR, 22.88; P =.003) and history of lupus nephritis (HR, 3.38; P =.01) increased the risk for disease flares.
The study had several limitations, including the retrospective design, single center, and lack of data on the impact of recently introduced drugs on disease flares.
“[L]ong term [hydroxychloroquine] treatment and prolonged disease remission exert a protective effect against flares and might prompt to withdraw low-dose steroids in patients [with] SLE. However, it might underline a caution in patients with SACQ disease who may be at greater risk for flare when GCs are discontinued,” the researchers concluded.
Fasano S, Coscia MA, Pierro L, Ciccia F. Which patients with systemic lupus erythematosus in remission can withdraw low dose steroids? Results from a single inception cohort study. Lupus. 2021;12:9612033211002269. doi:10.1177/09612033211002269