Restrictive Use of Oral Glucocorticoids in Systemic Lupus Erythematosus and Prevention of Damage Without Worsening Long‐Term Disease Control: An Observational Study

Ruiz-Arruza, Ioana; Lozano, J. Saavedra; Cabezas-Rodríguez, Iván; Medina, Jose-Alejandro; Ugarte, Amaia; Erdozain, Jose Gabriel; Ruiz‐Irastorza, Guillermo

doi:10.1002/acr.23322

Cited by 79 publications

(52 citation statements)

References 50 publications

(80 reference statements)

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“…Risks are substantially increased at continuous GC doses above 7.5 mg/day, with some studies suggesting that also lower doses might be harmful 17 42–44. To this end, two approaches can be considered: (1) use of pulses of intravenous methylprednisolone (MP) of various doses (depending on severity and body weight), which take advantage of the rapid non-genomic effects of GC45 and may allow for a lower starting dose and faster tapering of PO GC,46 47 and (2) early initiation of IS agents, to facilitate tapering and eventual discontinuation of oral GC ( see below ). High-dose intravenous MP (usually 250–1000 mg/day for 3 days) is often used in acute, organ-threatening disease (eg, renal, neuropsychiatric) after excluding infections 48…”

Section: Resultsmentioning

confidence: 99%

2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

et al. 2019

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Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.

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Section: Resultsmentioning

confidence: 99%

2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

et al. 2019

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“…Historically, glucocorticoids have been a cornerstone in the treatment of serious manifestations of NPSLE, especially in those associated with an inflammatory pathogenic pathway . Given the evidence linking glucocorticoid use to cumulative organ damage in SLE and the associated negative impact on HRQoL , alternative therapeutic strategies are necessary. In addition, glucocorticoids have been implicated as a cause of psychiatric symptoms in 2–60% of individuals , although it is more likely that this occurs in ~20% of cases .…”

Section: Current Status Of Npslementioning

confidence: 99%

Nervous System Disease in Systemic Lupus Erythematosus: Current Status and Future Directions

Hanly

Kozora

Beyea

et al. 2018

Arthritis & Rheumatology

119

103

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The American College of Rheumatology's case definitions for 19 neuropsychiatric syndromes in systemic lupus erythematosus (SLE) constitute a comprehensive classification of nervous system events in this disease. However, additional strategies are needed to determine whether a neuropsychiatric syndrome is attributable to SLE versus a competing comorbidity. Cognitive function is a clinical surrogate of overall brain health, with applications in both diagnosis and determination of clinical outcomes. Ischemic and inflammatory mechanisms are both key components of the immunopathogenesis of neuropsychiatric SLE (NPSLE), including abnormalities of the blood-brain barrier and autoantibody-mediated production of proinflammatory cytokines. Advances in neuroimaging provide a platform to assess novel disease mechanisms in a noninvasive way. The convergence of more rigorous clinical characterization, validation of biomarkers, and brain neuroimaging provides opportunities to determine the efficacy of novel targeted therapies in the treatment of NPSLE.

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“…Strategies aimed to reduce GC use through the universal prescription of hydroxychloroquine, the early use of immunosuppressive drugs together with the use of pulses of GCs and maintenance therapy with ≤5 mg/day have demonstrated success in reducing GC-related damage without increasing damage due to SLE 13…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2019

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ObjectivesTo evaluate the proportion of patients who have successfully withdrawn glucocorticoids (GCs) in a longitudinal cohort of patients with systemic lupus erythematosus (SLE) over a period of 6 years; to evaluate patient characteristics during GC withdrawal in relation to existing definitions of remission and Lupus Low Disease Activity State (LLDAS); and to evaluate the occurrence of flares after GC withdrawal.MethodsPatients who attempted GC withdrawal were identified for the cohort, and the following information was assessed during withdrawal attempts: date of last disease flare, disease activity and damage and ongoing treatment. Information regarding the occurrence of disease flares after GC withdrawal was also recorded for patients who successfully stopped treatment.Definitions of remission were applied to GC withdrawal in line with European consensus criteria (Definitions of remission in SLE [DORIS]) and LLDAS in line with the Asian Pacific Lupus Consortium definition.Results148 patients were involved in the study; GC withdrawal was attempted in 91 patients (61.5%) with 77 patients (84.6%) successfully stopping GCs. At the beginning of the GC reduction, the majority of patients were in complete or clinical remission (48.9% and 39.6%, respectively). Disease activity was significantly lower in patients who successfully stopped GCs, and the proportion of patients in complete remission was higher (54.2%) with respect to patients who failed in their attempt. Among patients who stopped GCs, 18 flares were recorded after a median of 1 year. The time period since the last flare was shorter in patients who experienced flares with respect to patients who did not flare (mean 0.93 years vs 6.0, p<0.001).ConclusionsGC withdrawal is an achievable goal in SLE and may be attempted after a long-term remission or LLDAS to protect the patient from disease flares.

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Restrictive Use of Oral Glucocorticoids in Systemic Lupus Erythematosus and Prevention of Damage Without Worsening Long‐Term Disease Control: An Observational Study

Abstract: The use of reduced oral prednisone doses, which was possible by combining different therapies, reduced glucocorticoid-related damage and improved CV prognosis without increasing damage caused by SLE.

Cited by 79 publications

References 50 publications

2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

Nervous System Disease in Systemic Lupus Erythematosus: Current Status and Future Directions

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

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