Background/Purpose: Proposed targets of SLE treatment include lupus low disease activity state (LLDAS), clinical remission and complete remission. Whether treatment can be tapered after achieving these targets and whether tapering will be safer in deeper states of remission compared to LLDAS are unknown.

Methods: We collected data from SLE patients (ACR/SLICC criteria) prospectively between 2013 to 2020 from 13 Asia-pacific countries. Disease activity was captured at each visit using SLEDAI-2K. We defined flares using SELEA-SLEDAI Flare Index. Tapering was defined as any decrease in dose of corticosteroids or immunosuppressive therapy (MMF, CSA, AZA, LEF, MTX or tacrolimus). We studied all visits that had achieved target, including LLDAS¹, 2021 DORIS definition of clinical remission (clinical SLEDAI=0, PGA< 0.5, prednisolone ≤5mg/day)² or DORIS complete remission on therapy (SLEDAI-2K=0, PGA< 0.5, prednisolone ≤5mg/day)³. Using multivariable generalized estimating equations, we compared flares at the subsequent visit, after drug tapering versus continuing the same therapy.

We then further analyzed tapering that occurred across visits by grouping consecutive visits into a single “tapering attempt”. A tapering attempt began with any taper of corticosteroids or immunosuppressive therapy at one of the target SLE states and ended at a visit when the dose of corticosteroid or immunosuppressive agent was increased. We used multivariable COX-proportional hazards to analyze the time to first flare, comparing attempts which had begun in LLDAS, clinical remission and complete remission.

Results: We included 3002 patients and 14808 patient-visits that had achieved one of the target SLE states (LLDAS, clinical remission or complete remission). Tapering occurred in 3521 visits (23.8%) and 11287 (76.2%) continued on the same therapy. 1679 flares (12.8%) were captured at the next visit. Tapering was associated with 1.24 higher odds of flare compared to continuing same therapy (p< 0.01). Other statistically significant associations included use of antimalarials, country, adjusted mean SLEDAI, disease duration and cumulative LLDAS/remission duration before taper (Table 1).

We recorded 2095 tapering attempts, of which 41.1%, 28.4% and 30.5% were initiated in LLDAS, clinical remission and complete remission respectively. The median (IQR) time to flare was 238 (33-443) days. Tapering attempts that were initiated in complete remission had a significantly longer time to first flare compared to attempts that were initiated in clinical remission or LLDAS (HR 0.79, p=0.009, Figure 1). Other significant variables associated with longer time to flare included country, duration of LLDAS/remission more than 30 days before taper, older age, shorter disease duration and lower adjusted mean SLEDAI (Table 2).

Conclusion: Tapering of corticosteroids or immunosuppressive therapy in stable SLE was associated with increased flares. Attaining complete remission was more protective against flares upon drug tapering as compared to attaining LLDAS or clinical remission. Drug tapering should be carefully considered in stable SLE patients irrespective with LLDAS or either type of remission.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/tapering-of-corticosteroids-or-immunosuppressive-therapy-in-stable-sle-a-comparison-of-complete-remission-clinical-remission-and-lupus-low-disease-activity-state-in-protection-against-flares/