Background/Purpose: Some patients with SLE achieve PCQ.  We previously described patients achieving corticosteroid- and immunosuppressive-free PCQ.  As physicians attempt to minimize patients’ exposure to these medications given their associated morbidities, this study’s aims were to describe patients who achieve PCQ maintained on these medications and to compare them to those maintaining medication-free PCQ. 

Methods: Patients followed regularly in the Lupus Clinic from July 1970 – October 2011 were identified.  PCQ was defined as SLEDAI-2K=0 or =2 or 4 from active serology for ≥5 consecutive years, with visits ≤18 months apart, in patients consistently maintained on corticosteroids and/or immunosuppressives (“MED“).  Charts were reviewed to qualitatively characterize the PCQ period.  MED demographics and clinical course before and during PCQ were then compared to patients who achieved PCQ, defined above, but without the use of corticosteroids or immunosuppressives for its duration (“NO MED”).  Descriptive statistics were used.  Comparisons were made using t- and McNemar’s tests. 

Results: 34/1613 (2.1%) MED patients were identified.  Mean MED PCQ duration was 8.5±2.9 (range 5.1-16.3) years, and ended with flare in 12 patients (35.3%).  In the 22 (64.7%) patients whose PCQ did not end in flare, medications were successfully discontinued in five (14.7%), being tapered in 6 (17.6%), maintained in two (5.9%) with organ transplants necessitating ongoing immunosuppression; six (17.6%) patients were maintained on a stable regimen, with no standardized drug withdrawal algorithm specified; three patients (8.8%) were lost to follow up. 

38/1613 (2.4%) NO MED patients were identified, with mean PCQ duration 11.6±6.4 (range 5.1–29.4) years.  When the groups were compared, MED patients were younger at diagnosis (27.9±11.7 versus 36.1±15.2; p=0.01) and required more immunosuppressives (52.9% versus 23.7%; p=0.01) and corticosteroid (100% versus 57.9%; p<0.0001) at higher cumulative doses (42.9±39.7 versus 20.7±17.2 grams (among those requiring corticosteroids; n=22); p=0.006) prior to PCQ.  There was no between–group difference in ethnicity, SLEDAI at presentation, antimalarial use, time to PCQ, organ manifestations, autoantibody profile, or SLICC damage index prior to, during, or at the last PCQ visit.

Conclusion:  2.1% of our cohort achieves PCQ of ≥5 years on corticosteroids and/or immunosuppressives; however, this group appears heterogeneous: the minority who flared, representing a group whose disease activity is merely suppressed by ongoing medication use, and the majority who tolerated/were tolerating medication withdrawal, reflective of true PCQ (as in NO MED).  Further comparison between these (remission versus suppression) subgroups compared to the NO MED cohort may be instructive as each may reflect unique pathophysiology.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-comparison-of-systemic-lupus-erythematosus-sle-patients-achieving-prolonged-clinical-quiescence-pcq-on-and-off-corticosteroids-andor-immunosuppressive-medications/