Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study
Objective Glucocorticoid (GC) tapering and withdrawal to reduce damage represents a key aspect of the European Alliance of Associations for Rheumatology (EULAR) SLE recommendations. However, optimal strategies for relapse-free GC cessation remain ill-defined. We characterised clinical predictors and...
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BMJ Publishing Group
2025-01-01
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| Online Access: | https://rmdopen.bmj.com/content/11/1/e005118.full |
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| author | Alessandra Bortoluzzi Marcello Govoni Dimitrios T Boumpas Antonis Fanouriakis Prodromos Sidiropoulos George Bertsias Konstantinos Parperis Argyro Repa Ettore Silvagni Myrto Nikoloudaki Nestor Avgoustidis Sofia Pitsigavdaki Antonio Marangoni Irini Flouri Spyridon Katechis |
| author_facet | Alessandra Bortoluzzi Marcello Govoni Dimitrios T Boumpas Antonis Fanouriakis Prodromos Sidiropoulos George Bertsias Konstantinos Parperis Argyro Repa Ettore Silvagni Myrto Nikoloudaki Nestor Avgoustidis Sofia Pitsigavdaki Antonio Marangoni Irini Flouri Spyridon Katechis |
| author_sort | Alessandra Bortoluzzi |
| collection | DOAJ |
| description | Objective Glucocorticoid (GC) tapering and withdrawal to reduce damage represents a key aspect of the European Alliance of Associations for Rheumatology (EULAR) SLE recommendations. However, optimal strategies for relapse-free GC cessation remain ill-defined. We characterised clinical predictors and their combined effect on flares in patients with SLE who discontinued GC.Methods Retrospective cohort of 324 patients with active SLE (PGA ≥1.5 and/or SLEDAI-2K ≥6) who received GC as part of treatment intensification (median follow-up 60 months). Survival and generalised linear models estimated SELENA-SLEDAI flare risks and their predictors.Results GCs were discontinued in 220 (67.9%) patients with 1-year risks for overall and severe flares of 50% and 25%, respectively (HR: 1.48; 95% CI: 1.12 to 1.96 for overall flares; HR: 1.52; 95% CI: 1.03 to 2.25 for severe flares, compared with non-withdrawers). Flare risk was lowered when GCs were ceased during remission (DORIS) or Lupus Low Disease Activity State (LLDAS; excluding remission) (HR for severe flares: 0.23; 0.12 to 0.43 and 0.30; 0.18 to 0.50, respectively), with each additional month in targets providing further protection. Hydroxychloroquine prevented total (HR: 0.37; 0.26 to 0.53) and severe flares (HR: 0.33; 0.21 to 0.52), while mycophenolate and azathioprine reduced overall flares. Prednisone tapering from 7.5 mg/day to 0 over >6 months improved severe flare-free outcome (HR: 0.57; 0.37 to 0.90). Random survival forests identified DORIS/LLDAS, hydroxychloroquine use and slow GC tapering as top predictors, whose coexistence reduced overall and severe flares by ~25 fold and ~50 fold, respectively. This combination reduced damage (IRR: 0.31; 0.08 to 0.84) without inducing flares (IRR: 0.52; 95% CI: 0.18 to 1.16) compared with GC non-withdrawers.Conclusion Low or absent disease activity, slow tapering and hydroxychloroquine use minimise the risk of flares, facilitating GC discontinuation—a major goal in SLE. |
| format | Article |
| id | doaj-art-d1694d2062ad4195bd32f63ac790d912 |
| institution | Kabale University |
| issn | 2056-5933 |
| language | English |
| publishDate | 2025-01-01 |
| publisher | BMJ Publishing Group |
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| series | RMD Open |
| spelling | doaj-art-d1694d2062ad4195bd32f63ac790d9122025-01-07T04:50:09ZengBMJ Publishing GroupRMD Open2056-59332025-01-0111110.1136/rmdopen-2024-005118Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort studyAlessandra Bortoluzzi0Marcello Govoni1Dimitrios T Boumpas2Antonis Fanouriakis3Prodromos Sidiropoulos4George Bertsias5Konstantinos Parperis6Argyro Repa7Ettore Silvagni8Myrto Nikoloudaki9Nestor Avgoustidis10Sofia Pitsigavdaki11Antonio Marangoni12Irini Flouri13Spyridon Katechis14Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, ItalyRheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, ItalyRheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens School of Medicine, Athens, GreeceRheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens School of Medicine, Athens, GreeceRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceDivision of Rheumatology, Department of Medicine, University of Cyprus Medical School, Nicosia, CyprusRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, ItalyRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliero-Universitaria S.Anna, Ferrara, ItalyRheumatology and Clinical Immunology, University of Crete School of Medicine, Heraklion, GreeceRheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens School of Medicine, Athens, GreeceObjective Glucocorticoid (GC) tapering and withdrawal to reduce damage represents a key aspect of the European Alliance of Associations for Rheumatology (EULAR) SLE recommendations. However, optimal strategies for relapse-free GC cessation remain ill-defined. We characterised clinical predictors and their combined effect on flares in patients with SLE who discontinued GC.Methods Retrospective cohort of 324 patients with active SLE (PGA ≥1.5 and/or SLEDAI-2K ≥6) who received GC as part of treatment intensification (median follow-up 60 months). Survival and generalised linear models estimated SELENA-SLEDAI flare risks and their predictors.Results GCs were discontinued in 220 (67.9%) patients with 1-year risks for overall and severe flares of 50% and 25%, respectively (HR: 1.48; 95% CI: 1.12 to 1.96 for overall flares; HR: 1.52; 95% CI: 1.03 to 2.25 for severe flares, compared with non-withdrawers). Flare risk was lowered when GCs were ceased during remission (DORIS) or Lupus Low Disease Activity State (LLDAS; excluding remission) (HR for severe flares: 0.23; 0.12 to 0.43 and 0.30; 0.18 to 0.50, respectively), with each additional month in targets providing further protection. Hydroxychloroquine prevented total (HR: 0.37; 0.26 to 0.53) and severe flares (HR: 0.33; 0.21 to 0.52), while mycophenolate and azathioprine reduced overall flares. Prednisone tapering from 7.5 mg/day to 0 over >6 months improved severe flare-free outcome (HR: 0.57; 0.37 to 0.90). Random survival forests identified DORIS/LLDAS, hydroxychloroquine use and slow GC tapering as top predictors, whose coexistence reduced overall and severe flares by ~25 fold and ~50 fold, respectively. This combination reduced damage (IRR: 0.31; 0.08 to 0.84) without inducing flares (IRR: 0.52; 95% CI: 0.18 to 1.16) compared with GC non-withdrawers.Conclusion Low or absent disease activity, slow tapering and hydroxychloroquine use minimise the risk of flares, facilitating GC discontinuation—a major goal in SLE.https://rmdopen.bmj.com/content/11/1/e005118.full |
| spellingShingle | Alessandra Bortoluzzi Marcello Govoni Dimitrios T Boumpas Antonis Fanouriakis Prodromos Sidiropoulos George Bertsias Konstantinos Parperis Argyro Repa Ettore Silvagni Myrto Nikoloudaki Nestor Avgoustidis Sofia Pitsigavdaki Antonio Marangoni Irini Flouri Spyridon Katechis Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study RMD Open |
| title | Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study |
| title_full | Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study |
| title_fullStr | Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study |
| title_full_unstemmed | Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study |
| title_short | Combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus (SLE): results from a multicentre, retrospective cohort study |
| title_sort | combination of clinical factors predicts successful glucocorticoid withdrawal in systemic lupus erythematosus sle results from a multicentre retrospective cohort study |
| url | https://rmdopen.bmj.com/content/11/1/e005118.full |
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