Background: Patients with Systemic Lupus Erythematosus (SLE) are often treated with prolonged maintenance therapy with immunosuppressants (ISs) after remission achievement, with the aim of avoiding disease flares and subsequent organ damage. Data on the risk of flare after IS discontinuation and the effect of IS discontinuation on damage accrual are scanty.
Objectives: Our aims were to analyze damage progression in remitted SLE patients who did or did not discontinued ISs, to assess flare rate after IS withdrawal and to compare damage accrual in patients who did or did not flare after IS discontinuation.
Methods: We considered all SLE patients included in our lupus database, diagnosed between 1990 and 2018 (ACR criteria), treated with immunosuppressants over their disease course, who discontinued IS due to remission. IS discontinuation was defined as complete withdrawal of any immunosuppressive drug, and remission as clinical SLE Disease Activity Index (SLEDAI)-2K=0. Flares were defined according to SLEDAI Flare Index, and damage according to SLICC damage Index (SDI).
Results: Eligible patients ever treated with ISs were 319 out of 456 (69.9%) currently in follow-up. Remission lasting at least 6 months was achieved by 206 patients treated with IS (64.6%) (Table 1); among them 105 (51%) discontinued ISs during the follow-up. Mean±SD follow-up after IS withdrawal was 91±71 months (range 6-372). No difference in damage accrual between remitted patients who discontinued or did not discontinue ISs was observed at the end of follow-up, after adjusting for disease duration: median (range) SDI 1 (0-6) and 0 (0-4), respectively. Accordingly, the proportion of remitted patients who accrued damage during the follow-up was similar between those who did or did not discontinue ISs (55% vs. 48%). Among patients who discontinued ISs, 26 (24.7%) experienced a flare after a median (range) of 57 (6-264) months from IS discontinuation. Flares were severe in 50% of cases (Table 2). No difference in damage progression between patients who flared and did not flare after IS withdrawal was found at the end of follow-up: median (range) SDI 1 (0-5) and 1 (0-6), respectively. Moreover, the proportion of patients with damage accrual was similar among patients with and without flare after IS discontinuation (56% vs. 54%).
Characteristics of remitted patients according to the discontinuation of ISs. Data are expressed as mean±SD or number (%).
Remitted patients | P value | ||
---|---|---|---|
IS discontinued (105) | IS not discontinued (101) | ||
Female, N (%) | 93 (88.6) | 85 (84.1) | n.s. |
Age at 2018, years | 44±11 | 40±12 | 0.035 |
SLE duration at 2018, years | 19.5±9.2 | 12.3±8.7 | 0.027 |
SLE duration at remission, years | 5.2±6.1 | 6.3±4.2 | n.s. |
Remission lasting at IS discontinuation > 2 consecutive years, N (%) | 66 (63) | 36 (35.6) | 0.001 |
Reason for IS therapy, N (%) | |||
Lupus Nephritis | 68 (64.8) | 57 (56.4) | n.s. |
Skin involvement | 6 (5.7) | 7 (6.9) | |
Arthritis | 12 (11.4) | 15 (14.4) | |
Haematological involvement | 5 (4.7) | 8 (7.9) | |
Neuropsychiatric involvement | 3 (2.9) | 2 (1.9) | |
Vasculitis | 3 (2.9) | 1 (0.9) | |
Multisystemic involvement | 8 (7.6) | 11 (11) | |
Type of last IS*, N (%) | |||
Mycophenolate | 48 (45.7) | 73 (72.2) | 0.001 |
Azathioprine | 30 (28.6) | 18 (17.8) | 0.04 |
Methotrexate | 14 (13.3) | 5 (4.9) | 0.008 |
Cyclosporine | 7 (6.7) | 4(3.9) | n.s. |
Cyclophosphamide | 6 (5.7) | 1 (0.9) | 0.001 |
* last IS used before withdrawal or at last visit. Multisystemic: involvement of more than 2 organs requiring IS therapy.
Type of flare after IS discontinuation in 105 SLE remitted patients.
Type of flare | Number (%) | Severe flare, number (% of all flares) |
---|---|---|
Arthritis | 5 (19.2) | 2 (7.7) |
Skin manifestations | 6 (23.1) | 1 (3.9) |
Serosal involvement | 2 (7.7) | 0 |
Haematological involvement | 5 (19.2) | 2 (7.7) |
Lupus nephritis | 8 (30.8) | 8 (30.8) |
Total | 26 | 13 (50) |
Conclusion: In our SLE cohort, the withdrawal of IS therapy in remitted patients did not seem to influence damage progression in the medium-term.
Disclosure of Interests: None declared
DOI: 10.1136/annrheumdis-2019-eular.7808