Background/Purpose:

Despite improved survival rates in systemic lupus erythematosus (SLE) over the last 4 decades, organ damage and associated morbidity continues over time. Corticosteroids (CS) contribute to this accrual of damage. Due to the reliance on CS in the treatment of SLE there is a paucity of data on the disease characteristics of those that remain CS-naïve.

We hypothesized that CS-naïve patients with SLE accrue less damage and at a slower rate than CS-exposed patients, and that initiation of antimalarial medication (AM) soon after diagnosis may reduce exposure to CS over time.

Methods: Patients with SLE attending a large lupus clinic with 3 years or more of follow-up from inception, in the absence of damage (as per the SLICC Damage Index (SDI)) or exposure to CS at the inception visit, were included in the analysis. Two groups were identified from this cohort: those who remained CS-naïve up to their last visit at the Clinic and those who were exposed to CS at any point during follow-up.  Differences in the rate of exposure to AM, rate of organ damage accrual (SDI ≥ 1) and disease activity at inception (SLEDAI-2K) and over time (adjusted mean SLEDAI (AMS) were examined. Organ-specific damage at the last Clinic visit was sub-classified as: ‘definitely steroid-related’ (e.g. osteonecrosis), ‘possibly steroid-related’ (e.g. myocardial infarction), and ‘unrelated to steroid’ (e.g. chronic kidney disease). A generalized linear model with repeated measures was used to assess the increase in damage over fifteen years in the two groups.

Results:

From 209 patients fulfilling inclusion criteria, 84 remained CS-naïve from inception to the last recorded visit, while 125 were exposed to CS at some point during the disease course. Mean disease duration at first exposure to CS was 3.8 ± 5.5 years. Gender, race and age (37 ± 14.2 years in the CS-naïve group vs 35.1 ± 13.5 years in the CS-exposed (p=0.33)) were similar between the 2 groups at diagnosis. Baseline SLEDAI-2K was lower in the CS-naïve group (5.48 ± 3.53) compared with the CS-exposed (8.12 ± 5.93; p<0.0001). The AMS at all time points up to 10 years after diagnosis was significantly greater in the CS-exposed group. In the CS-naïve group, 35.7% developed damage during their disease course compared to 60.8% of the CS-exposed (p=0.0004). Mean SDI was significantly greater 1 year after diagnosis in the CS-exposed compared to the CS-naïve (0.14 ± 0.43 vs 0.02 ± 0.15, p=0.008) and at bi-annual intervals up to 15 years (1.52 ± 1.59 vs 0.54 ± 0.75, p<0.0001). On average, CS-naïve patients accrued damage at the rate of 0.05 per year compared to 0.10 per year in the CS-exposed patients (p=0.003). The increase in damage over 15 years ‘definitely’ and ‘possibly’ CS-related was significantly greater in the CS-exposed compared with the CS-naïve (p=0.009 and 0.024, respectively), but not in damage ‘unrelated to CS’ (p=0.3).  Within the first year from inception, 51% of the CS-naïve and 61% of the CS-exposed groups were prescribed AM (p=0.17)

 Conclusion:

One third of CS-naïve SLE patients accrue damage over time, yet develop less damage and at a slower rate than those exposed to CS. Disease activity is lower in those naïve of CS, while early initiation of AM does not reduce exposure to CS.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-accrual-of-damage-in-corticosteroid-naive-patients-with-systemic-lupus-erythematosus/