Clinicians approaches to management of background treatment in patients with SLE in clinical remission: results of an international observational survey

Abstract

BackgroundThe definition of remission in systemic lupus erythematosus (SLE) remains unclear, especially how background treatment should be interpreted.ObjectiveTo determine preferences of clinicians in treatment of patients in clinical remission from SLE and to assess how previous severity, duration of remission and serology influence changes in treatment.MethodsWe undertook an internet-based survey of clinicians managing patients with SLE. Case scenarios were constructed to reflect different remission states, previous organ involvement, serological abnormalities, duration of remission and current treatment (hydroxychloroquine (HCQ), steroids and/or immunosuppressive (ISS) agents).Results130 clinicians from 30 countries were surveyed. The median (range) duration of practice and number of patients with SLE seen each month was 13 (2–42) years and 30 (2–200), respectively. Management decisions in all scenarios varied with greater caution in treatment reduction with shorter duration of remission, extent of serological abnormalities and previous disease severity. Even with mild disease, normal serology and a 5-year clinical remission, 113 (86.9%) clinicians continue to prescribe HCQ. Persistent abnormal serology in any scenario led to a reluctance to reduce or discontinue medications. Prescribing in remission, particularly of steroids and HCQ, varied significantly according to geographical location.ConclusionsClinicians preferences in withdrawing or reducing treatment in patients with SLE in clinical remission vary considerably. Serological abnormalities, previous disease severity and duration of remission all influence the decision to reduce treatment. It is unusual for clinicians to stop HCQ even after prolonged periods of clinical remission. Any definition(s) of remission needs to take into consideration such evidence on how maintenance treatments are managed.

Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial

“…GCs tapering and withdrawal are considered one of the main targets of SLE management, but at present the decision of withdraw GCs is left to the judgement of the treating physician. A recent internet-based survey of 130 clinicians from 30 countries showed that preference of clinicians in treatment reduction in patients with SLE in clinical remission was variable with greater caution in treatment reduction when patients have persistent serological abnormalities and previous major organ involvement 5. Prednisolone was by far the first medication that physician suggested reducing or withdrawing during remission, irrespective of persistent serological abnormalities, remission duration, minor or major organ involvement and whether prednisolone was used with hydroxychloroquine (HCQ) alone or as part of a regimen also involving HCQ and an immunosuppressant 5.…”

“…Glucocorticoids (GCs) play a central role in the treatment of active SLE but little data are available on GC withdrawal for patients once remission has been achieved 1–4. Although there is general agreement on the toxicity of GCs and the need to avoid long-term administration of these drugs, a significant proportion of treating physicians prefers to continue low-dose GCs despite clinical remission, particularly if there is a history of major organ involvement such as lupus nephritis or neuropsychiatric SLE 5. Observations of SLE cohorts reported that between 57% and 86% of patients undergo long-term low-dose GCs treatment 6 7…”

Glucocorticoid withdrawal in systemic lupus erythematosus: are remission and low disease activity reliable starting points for stopping treatment? A real-life experience

“…A recent survey showed that clinicians’ preferences in withdrawing GCs in patients with SLE in clinical remission are highly variable: serological abnormalities, previous disease severity and duration of remission are the most recurrent variables that influence this decision 21…”

“…According to a recent internet-based survey of 130 clinicians from 30 countries, a longer duration of clinical remission (>5 years) with normal serology is associated with approximately a 35% likelihood of GC withdrawal; however, a significant proportion of patients are kept on GCs by their treating physician despite clinical remission, particularly if there is a history of severe organ involvement. From the same survey, serology emerged as the main influencer for the physician’s decision to withdraw GCs 21…”

Possibilities and prospects for glucocorticoid withdrawal in systemic lupus erythematosus

“…Действительно, наличие ремиссии или низкой активности является логичным основанием для решения вопроса о прекращении терапии ГК, принципиальное значение при этом имеет современная дефиниция состояния ремиссии СКВ [20]. Так, по данным опроса 130 клиницистов из 30 стран, длительная клиническая ремиссия СКВ (≥5 лет) и нормальные иммунологические показатели послужили основанием для отмены ГК у 35% больных [21]. В одном из последних исследований анализируется феномен отмены ГК у 91 из 148 пациентов в когорте СКВ, находившихся под наблюдением с 2012 по 2017 г.…”