Maintenance of remission has become central in the management of systemic lupus erythematosus (SLE). However, an active disease-free state is generally maintained only when patients are on medication, which often leads to treatment-related complications. Therefore, once remission has been achieved, prolonged maintenance treatment inevitably requires a regimen of drug de-escalation. The recent EULAR recommendations for the treatment of SLE during chronic maintenance treatment advocate that glucocorticoids (GC) should be, when possible, withdrawn.1 However, in routine practice a significant proportion of treating physicians prefers to continue a low dose GC regimen, despite clinical remission, which is most likely due to the fear that withdrawal of low-dose GCs may lead to a severe flare, even after very long intervals of remission.2 In a recent prospective randomised controlled trial, we showed that, in SLE patients in remission and with stable treatment regimen for at least 1 year, withdrawal of 5 mg of prednisone was associated with a fourfold increase (i.e. 27%), in the risk of flare, as defined by the SFI or the BILAG index.3 Other SLE treatments remained unmodified during this study. In particular, at study entry 91% and 27% of the patients were also treated with hydroxychloroquine and an immunosuppressant, respectively. The 27% relapse rate observed in the withdrawal group in our study is in line with the ones recently reported in two recent cohorts.4 5 Tani et al described the longitudinal study of a cohort of 91 SLE Italian patients who attempted stopping GC treatment.4 A total of 77 patients successfully stopped GC. For those patients who were successfully withdrawn from GC, 18 flares (23%) were recorded after a median follow-up period of about 2 years. As in our study, 72% of flares were mild. The time period since the last flare was the sole determinant predictor of disease flare identified. A recent observational study, performed by Goswami et al in India, reported that 21% of patients in remission undergo exacerbation of the disease after GC withdrawal with most of the flares occurring in the first year of follow-up.5 Therefore, until the availability of effective drugs with little or no toxicity, it is recommended to not abandon the option of using very low doses of GCs (i.e. ≤5 mg prednisone) given their potential benefits in SLE patients in remission, especially those at low cardiovascular risk.
Define remission in SLE patients
Discuss drug de-escalation in SLE patients in remission
Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis2019;78(6):736–45.
Ngamjanyaporn P, McCarthy EM, Sergeant JC, et al. Clinicians approaches to management of background treatment in patients with SLE in clinical remission: results of an international observational survey. Lupus Sci Med 2017;4(1):e000173.
Mathian A, Pha M, Haroche J, et al. Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial. Ann Rheum Dis 2020;79(3):339–46.
Tani C, Elefante E, Signorini V, et al. Glucocorticoid withdrawal in systemic lupus erythematosus: are remission and low disease activity reliable starting points for stopping treatment? A real-life experience. RMD open 2019;5(2):e000916.
Goswami RP, Sit H, Ghosh P, et al. Steroid-free remission in lupus: myth or reality; an observational study from a tertiary referral centre. Clin Rheumatol 2019;38(4):1089–97.
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