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Steroid-free remission in lupus: myth or reality; an observational study from a tertiary referral centre

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Abstract

Objective

Whether maintaining steroid-free remission is feasible in Indian patients with systemic lupus erythematosus (SLE).

Methods

In 148 patients with SLE including 78 lupus nephritis (LN) previously put into remission, steroid therapy was gradually tapered off.

Results

Patients received glucocorticoids for median 1855 days (interquartile range (IQR) 901–2834) before discontinuing. Median duration of follow-up was 539 days (IQR 266.25–840.75). Flare occurred in 31 patients (20.9%; 95% confidence interval (CI) 15.17–28.19, renal flare in 12.16% (18/148, 95% CI 7.83–18.41)). Most of the flares occurred in the first year of follow-up (41.9%, 13/31). Overall 93.5% (29/31) of flares occurred in those who received ≤ 8 years of glucocorticoids, compared to 6.5% (2/31) of flares in others (p = 0.009). Median flare-free survival was 611 days (95% CI 518–704). Multivariate Cox regression identified the following predictors of flare-free survival: duration of disease (hazard ratio (HR) 0.89, 95% CI 0.84–0.94, p < 0.001), duration of glucocorticoid before discontinuing (HR 1.000086, 95% CI 1.000047–1.00012, p < 0.001) and second immunosuppressive (HR 1.89, 95% CI 1.251–2.87, p = 0.003). Additional risk factors of a renal flare-free survival among patients with LN were initial dose of glucocorticoids (HR 0.97, 95% CI 0.94–0.99, p = 0.005) and presence of haemolytic anaemia (HR 2.43, 95% CI 1.067–5.54, p = 0.035).

Conclusions

About 20% patients undergo exacerbation of disease activity after glucocorticoid withdrawal. Treatment for ≥ 8 years before discontinuing and an additional immunosuppressive agent improve the chance of flare-free survival.

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Authors and Affiliations

  1. Department of Rheumatology, Institute of Post Graduate Medical Education and Research, 240 AJC Bose Road, Kolkata, West Bengal, India

    Rudra Prosad Goswami, Hiramanik Sit, Parasar Ghosh, Geetabali Sircar & Alakendu Ghosh

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  1. Rudra Prosad Goswami
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  2. Hiramanik Sit
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Correspondence to Parasar Ghosh.

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Rudra Prosad Goswami and Hiramanik Sit are joint first authors

Key messages

1. About 20% patients undergo disease-flare after glucocorticoid withdrawal, mostly within the first year

2. Glucocorticoid for ≥ 8 years before discontinuation and an additional immunosuppressive agent improve chance of flare-free survival

3. Neuropsychiatric flare is unlikely for a patient with baseline neuropsychiatric lupus, once in remission

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Goswami, R.P., Sit, H., Ghosh, P. et al. Steroid-free remission in lupus: myth or reality; an observational study from a tertiary referral centre. Clin Rheumatol 38, 1089–1097 (2019). https://doi.org/10.1007/s10067-018-4377-7

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  • DOI: https://doi.org/10.1007/s10067-018-4377-7

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