Tapering steroids in modified serologically active clinically quiescent patients with SLE

Serological activity in systemic lupus erythematosus (SLE) is characterized by the presence of anti-double-stranded DNA antibodies and/or hypocomplementemia. Some patients with SLE exhibit persistent serological activity, despite clinical quiescence. Appropriate use of glucocorticoid (GC) therapy and withdrawal in these serologically active, clinically quiescent (SACQ) patients needs to be investigated.

Katsumata et al. recently published an article in Annals of the Rheumatic Diseases assessing the risk of flare and damage accrual after tapering GCs in patients with modified SACQ (mSACQ; SACQ not-considering duration) with SLE.¹ Here, we summarize their key findings.

Methods¹

• Data were collected prospectively from a large multinational longitudinal cohort between 2013 and 2020.
• The primary outcome was disease flare and the secondary outcome was irreversible organ damage accrual (any increase in Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI] score).
• Cox proportional hazard models were used to assess the risk of subsequent flare or damage accrual per 1 mg decrease of prednisolone-equivalent GC dosages.
• Each initial dosages of prednisolone-equivalent GC were analyzed:
  • 0≤ and ≤5 (relevant to remission);
  • 0≤ and ≤7.5 (relevant to Lupus Low Disease Activity State); and
  • >5 and ≤7.5 (relevant to Lupus Low Disease Activity State but not in remission).

Key findings¹

• A total of 1,850 patients were studied, with 2 years of subsequent follow-up data since their initial mSACQ visit.

Flare

• Of 1,850 patients, 742 patients experienced overall flare and 271 experienced severe flare.
• Tapering GCs showed no association with an increased risk of subsequent overall or severe flare in any dosage groups (Figure 1).
• In contrast, among patients with initial prednisolone-equivalent GC dosages of 0–7.5 or 0–5 mg/day, antimalarial use was significantly associated with decreased risk of:
  • overall flare: hazard ratio (HR), 0.78; 95% confidence interval (CI), 0.66–0.91; p = 0.002; and
  • severe flare: HR, 0.59; 95% CI, 0.46–0.76; p < 0.001.

CI, confidence interval; GC, glucocorticoid; HR, hazard ratio; mSACQ, modified serologically active clinically quiescent; SLE, systemic lupus erythematosus.
*Data from Katsumata, et al.¹

 Damage accrual

• Of 1,677 mSACQ patients with available SDI data, 180 patients experienced new damage accrual.
• Tapering GCs was associated with a 4% decreased risk of damage accrual in the patients whose initial prednisolone dosages were 0–7.5 mg/day and >5 mg/day (Figure 1C).
• Use of antimalarials showed no association with damage accrual (HR, 1.10; 95% CI, 0.79–1.53; p = 0.59).

Key learnings

Tapering GCs did not increase the risk of subsequent flare in mSACQ patients with SLE and provided protection against damage accrual in those treated with >5 mg/day of prednisolone. Cautious tapering of GCs is a viable option in mSACQ-SLE, with low daily GC exposure (≤7.5 mg/day of prednisolone-equivalent); aiming to reduce steroid burden. Further studies are warranted to explore the best GC tapering strategies and protective benefits of biologics against flare in mSACQ patients with SLE.