Flares affect nearly a third of SLE patients after discontinuing immunosuppressants
medwireNews: Study results indicate that flares are common among patients with systemic lupus erythematosus (SLE) who withdraw from immunosuppressant treatment, but durable remission and antimalarial maintenance may protect against them.
The retrospective analysis found that among 319 patients with SLE, 139 (43.5%) discontinued their immunosuppressant treatment: 75.5% due to remission and 24.5% due to poor adherence or tolerance.
Of the 105 patients who discontinued because of remission and the 34 who discontinued due to poor adherence or tolerance, a respective 24.8% experienced a flare after a median of 57 months and 67.7% after a median of 8 months.
“These findings highlight the importance of adherence to therapy. Notably, misinterpretation of disease flares that are instead related to poor adherence may lead to unnecessary therapeutic changes,” say Andrea Doria (University of Padova, Italy) and study co-authors.
All the patients who achieved remission were receiving stable immunosuppressive and/or antimalarial treatment. And of these, 17 were in complete remission and were prednisone-free with a SLEDAI 2002 score of 0, while the 88 in clinical remission, with a clinical SLEDAI 2002 score of 0, were also taking a maximum of 5 mg prednisone a day.
Out of 13 severe flares, 12 occurred in patients who were in clinical remission, as did all seven incidences of renal flare. These results reinforce “the concept that the achievement of a deeper remission might reduce the risk of severe flares,” the researchers write in Rheumatology.
They report that for patients who discontinued immunosuppressant treatment, duration of remission at the time of discontinuation and receiving maintenance therapy with hydroxychloroquine were both significant factors associated with a lower risk for flare, with the latter being the “strongest independent protective factor.”
The researchers also note that “the protective effect of [hydroxychloroquine] against flare progressively increased as the duration of remission lengthened.”
Among patients taking hydroxychloroquine after withdrawal of immunosuppressant, who were in remission for 1, 2, or 3 years the risk for flare fell by 69%, 81%, and 86%, respectively, compared with patients who had been in remission for less than a year, or who were not taking hydroxychloroquine.
The team points out that no flares occurred in the 26 patients who had been in remission and taking hydroxychloroquine for 5 or more years.
The researchers therefore suggest “long-term background therapy with antimalarials should be recommended in all SLE patients.”
By contrast, glucocorticoid as a maintenance therapy offered little protection. They observed that among the remitted patients, those taking glucocorticoids had a higher risk for flare.
The researchers conclude: “[Immunosuppressant] withdrawal seems not to be applicable to all remitted patients and requires a personalized approach, considering the characteristics of each individual patient, including the maintenance therapy and the duration of remission.
“During treatment tapering and after withdrawal, a close surveillance should be planned, especially in the first months, in order to detect early signs or symptoms of disease relapse.”
By Hannah Kitt
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