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Abstract
Background The SLE Clinic at University College London Hospital (UCLH) has been running since 1978. During this period there have been major changes in the management of SLE, including successive introduction of cyclophosphamide, mycophenolate and rituximab, and increasing recognition of the adverse effects of corticosteroids and the benefits of hydroxychloroquine. We therefore carried out a retrospective analysis of use of drugs to treat patients with SLE in this clinic, particularly looking for patterns of usage that might vary with age at diagnosis, ethnicity, gender and decade of diagnosis.
Methods Medical records from 171 patients (Mean age at diagnosis=30, 93% female, mean follow-up 22 years) were assessed to see which drugs had ever been prescribed, according to the following outcome categories – any corticosteroids, higher dose corticosteroids (intravenous or >5 mg per day oral), hydroxychloroquine, immunosuppressants (IS) (including mycophenolate, azathioprine, cyclophosphamide, rituximab). We also looked at use of higher dose corticosteroids or IS in the first two years after diagnosis. We assessed whether each of these patterns of drug use varied between different patient groups.
Results Figure 1a shows that 134 (78%) of patients received steroids, 121 (71%) hydroxychloroquine and 98 (57%) IS. About a third (59 or 35%) received all three. Conversely, 33 (19%) received no drugs or hydroxychloroquine alone. 94% of those who received IS also got steroids.
There were no significant associations with gender or ethnicity except that a higher proportion of non-white patients than white received both higher dose corticosteroids and IS (36% vs 21% p=0.05). Figure 1b shows that use of most drugs was similar across all ages of onset, except that those diagnosed at >50 years had lower use of higher dose corticosteroids (40%) and azathioprine (10%) but higher use of cyclophosphamide (30%) than other groups.
Figure 1c shows a shift to increased early use of IS and higher dose corticosteroids in patients diagnosed in more recent decades. Cyclophosphamide use has continued despite introduction of rituximab and mycophenolate.
Conclusion This long-term retrospective analysis shows that over the course of disease 81% of patients received corticosteroids and/or immunosuppressants. Early aggressive immunosuppression has become more common.
A: all drugs. B: drugs stratified by age of SLE diagnosis. C: drugs stratified by decade of diagnosis