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

Abstract

Background: The definition of remission in systemic lupus erythematosus (SLE) remains unclear, especially how background treatment should be interpreted.

Objective: To 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.

Methods: We 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).

Results: 130 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.

Conclusions: Clinicians 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.

Keywords: Corticosteroids; Disease Activity; Remission; Systemic Lupus Erythematosus; serology.

Figure 1

Pattern of alteration of medications by physicians in a patient with mild SLE (skin and joint only), no evidence of clinical disease activity for 5 years and current normal serology according to the patients’ baseline medication regimen. The three scenarios vary according to the drug combination the patient is taking. HCQ, hydroxychloroquine; MTX, methotrexate; Pred, prednisolone.

Figure 2

The pattern of alteration of HCQ, prednisolone and/or ISS drugs by physicians in a patient with a history of major organ involvement from their SLE (renal and neuropsychiatric) in clinical remission for 5 years with no evidence of current serological activity. The four scenarios vary according to the serological abnormality. N/N, normal dsDNA/normal complement; P/N, abnormal dsDNA/normal complement; N/P, normal dsDNA/abnormal complement; P/P, abnormal dsDNA/abnormal complement; HCQ, hydroxychloroquine; ISS, immunosuppressive.

Figure 3

Longer duration of clinical remission is associated with increased likelihood of withdrawal of prednisolone and ISS drugs in a patient with SLE with previous major organ involvement and current normal serology. The four scenarios vary according to serological abnormality. N/N, normal dsDNA/normal complement; P/N, abnormal dsDNA/normal complement; N/P, normal dsDNA/abnormal complement; P/P, abnormal dsDNA/abnormal complement; ISS, immunosuppressive.

Figure 4

The pattern of alteration of HCQ, prednisolone and/or ISS drugs by physicians in a patient with a history of major organ involvement from their SLE (renal and neuropsychiatric) in clinical remission for 1, 3 or 5 years is influenced by the presence of current serological activity (stems 2–4). The four scenarios vary according to the serological abnormality presented to the physician. N/N, normal dsDNA/normal complement; P/N, abnormal dsDNA/normal complement; N/P, normal dsDNA/abnormal complement; P/P, abnormal dsDNA/abnormal complement; ISS, immunosuppressive. Antimalarial agents, prednisolone, immunosuppressive drugs: CCC, continue, continue, continue; CRC, continue, reduce, continue; CRR, continue, reduce, reduce; CWC, continue, withdraw, continue; CWW, continue, withdraw, withdraw. HCQ, hydroxychloroquine.