Background/Purpose: At present there is no consensus on what constitutes a remission in SLE. In particular it is not clear how background therapy should be interpreted in remission studies. We aimed to survey clinicians involved in the care of SLE patients to determine how background therapy is managed in patients in clinical remission and in particular to assess how previous severity, duration of remission and serological parameters influence therapy alterations. 

Methods: We undertook an internet-based survey of clinicians involved in the management of SLE. Case scenarios were constructed to reflect different states of clinical remission; previous organ involvement, current serological abnormalities, duration of remission (1, 3 and 5 years) and current therapy (HCQ, steroids and/or immunosuppressives[ISS]). The survey link was sent to (1) the corresponding authors from Lupus Journal published between January 2013 and December 2013 (2) Lupus working groups e.g. BILAG, SLICC. Percentage of responses in each scenario was described and compared between different factors.

Results: 130 clinicians from 30 countries (Europe 54 [41.5%], Asia 53 [40.8%], North America 16 [12.3%]) responded including 113 (86.9%) rheumatologists. The median (range) duration of practice and number of SLE patients seen per month was 13 (2, 42) years and 30 (2, 200) respectively. There was variation in management decisions across all scenarios with increasing caution on therapy 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 104 (86.7%) clinicians would still continue HCQ, with only 16 (13.3%) stopping the drug. Similarly, when low dose steroid are co-prescribed in this scenario 78 (64.5%) would continue these and 116 (96.7%) would continue HCQ. When MTX is added to this scenario 85 (70.2%), 79 (67.8%), and 116 (96.7%) would continue all therapies. Of interest, persistent abnormal serology in the above scenario led to a higher proportion of respondents continuing HCQ 113 (96.6%). Similarly, 106 (89.1%) would continue steroid and 119 (100%) would continue HCQ when patients were prescribed both. Prescribing in remission scenarios varied geographically, particularly with regard to steroids. For example, in the scenario describing stable, mild disease for 5 years, steroids would be withdrawn by 24 (48%) European respondents, 4 (28.6%) North American respondents and 10 (19.6%) Asian physicians.

Conclusion: Clinicians approach to withdrawing or reducing therapy in patients with SLE in clinical remission varies substantially. Serological abnormalities, previous disease severity and duration of remission all influence a clinician’s decision to reduce treatments and anti-malarials are not usually withdrawn. It is unusual for clinicians to withdraw all therapies, even after a very prolonged period of clinical remission and therefore any definition of remission needs to include the continued use of some background maintenance therapies.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/clinicians-approaches-to-the-management-of-background-therapy-in-sle-patients-in-clinical-remission-results-of-an-international-survey/