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801 Factors associated with SLE flares after HCQ taper, discontinuation or maintenance in the SLICC inception cohort: lower education linked with higher flare risk
  1. Celline C Almeida-Brasil1,
  2. John G Hanly2,
  3. Murray B Urowitz3,
  4. Ann E Clarke4,
  5. Rosalind Ramsey-Goldman5,
  6. Caroline Gordon6,
  7. Michelle A Petri7,
  8. Ellen M Ginzler8,
  9. Daniel J Wallace9,
  10. Sang-Cheol Bae10,
  11. Juanita Romero-Diaz11,
  12. Mary Anne Dooley12,
  13. Christine A Peschken13,
  14. David A Isenberg14,
  15. Anisur Rahman14,
  16. Susan Manzi15,
  17. Soren Jacobsen16,
  18. Sam Lim17,
  19. Ronald van Vollenhoven18,
  20. Ola Nived19,
  21. Andreas Jonsen19,
  22. Diane L Kamen20,
  23. Cynthia Aranow21,
  24. Guillermo Ruiz-Irastorza22,
  25. Jorge Sanchez-Guerrero3,
  26. Dafna D Gladman3,
  27. Paul R Fortin23,
  28. Graciela S Alarcón24,
  29. Joan T Merrill25,
  30. Kenneth C Kalunian26,
  31. Manuel Ramos-Casals27,
  32. Kristjan Steinsson28,
  33. Asad Zoma29,
  34. Anca Askanase30,
  35. Munther A Khamashta31,
  36. Ian Bruce32,
  37. Murat Inanc33 and
  38. Sasha Bernatsky1
  1. 1Research Institute of the McGill University Health Centre, Canada
  2. 2Queen Elizabeth II Health Sciences Centre, Canada
  3. 3University of Toronto, Canada
  4. 4University of Calgary, Canada
  5. 5Northwestern University, USA
  6. 6Institute of Inflammation and Ageing of the University of Birmingham, UK
  7. 7Johns Hopkins University School of Medicine, USA
  8. 8SUNY Downstate Medical Center, USA
  9. 9Cedars-Sinai Medical Centre, USA
  10. 10Hanyang University Hospital for Rheumatic Diseases, South Korea
  11. 11Instituto Nacional de Ciencias Médicas y Nutrición, Mexico
  12. 12UNC Kidney Centre, USA
  13. 13University of Manitoba, Canada
  14. 14University College London, UK
  15. 15Allegheny Health Network, USA
  16. 16Rigshospitalet, Denmark
  17. 17Emory University School of Medicine, USA
  18. 18University of Amsterdam, Netherlands
  19. 19Lund University, Sweden
  20. 20Medical University of South Carolina, USA
  21. 21Feinstein Institute for Medical Research, USA
  22. 22Hospital Universitario Cruces, Spain
  23. 23Université Laval, Canada
  24. 24University of Alabama at Birmingham, USA
  25. 25Oklahoma Medical Research Foundation, USA
  26. 26UC San Diego School of Medicine, USA
  27. 27Universitat de Barcelona, Spain
  28. 28Landspitali University Hospital, Iceland
  29. 29Hairmyres Hospital, UK
  30. 30Columbia University Medical Centre, USA
  31. 31St Thomas’ Hospital, UK
  32. 32University of Manchester, UK
  33. 33Istanbul University, Turkey


Background Hydroxychloroquine (HCQ) is a cornerstone treatment of systemic lupus erythematosus (SLE). We compared time to flare in SLE patients discontinuing/reducing HCQ versus those maintaining their dose, and identified factors associated with time to flare.

Methods We analyzed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, which includes SLE patients from 33 sites in Europe, Asia, and North America, enrolled within 15 months of diagnosis and followed annually (1999-2019). We identified patients with HCQ reduction/discontinuation, regardless of disease activity. We evaluated person-time that patients contributed on their initial dose (‘maintenance’), comparing this to person-time contributed after a first dose reduction, and person-time after a first HCQ discontinuation. We estimated time to first flare, defined as either subsequent need for therapy augmentation (steroids or other immunomodulators), increase of ≥4 points in the SLE Disease Activity Index-2000 (SLEDAI-2K) or hospitalization for SLE. We estimated crude flare rates for each sub-cohort and hazard ratios and 95% confidence intervals (CIs) for various demographic and clinical factors potentially associated with flare risk in the reduction and discontinuation sub-cohorts, as well as comparator maintenance sub-cohorts (matched for time on HCQ to the reduction and discontinuation sub-cohorts).

Results We studied 1460 SLE patients (90% women, 52% Caucasian) on HCQ. Of these, 592 subsequently reduced HCQ at any point, while 407 discontinued HCQ at any point. The crude flare rate for the HCQ reduction sub-cohort was 42.3 per 100 person-years (95% CI 38.6, 46.4), versus 35.6 (95% CI 32.4, 39.1) in the matched maintenance sub-cohort. In the discontinuation sub-cohort, the crude flare rate was 43.1 (95% CI 38.3, 48.4), versus 34.2 (95% CI 30.6, 38.2) in the matched maintenance sub-cohort. Table 1 shows the factors associated with time to flare within each sub-cohort. The hazard ratios are adjusted by all variables in the table. Prednisone or immunosuppressive use at time-zero was associated with higher flare risk in all analyses. Lower education was associated with higher risk of SLE flares among patients who discontinued HCQ. There was a trend across sub-cohorts for lower flare risk among patients from Asia, versus North America.

Abstract 801 Table 1

Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for SLE flare across sub-cohorts

Conclusions Compared to HCQ maintenance, crude flare rates were numerically higher after HCQ taper/discontinuation. SLE patients on prednisone or immunosuppressives were at higher risk for flare in all groups. The association between lower education and higher SLE flare risk was most clearly seen upon discontinuation of HCQ, suggesting this as a particularly vulnerable group.

Acknowledgements This research was supported by the Canadian Institutes of Health Research (CIHR).

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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