Clinicians approaches to management of background therapy in Systemic Lupus Erythematosus patients in clinical remission: Results of an international observational survey

Objective: The definition of remission in SLE remains unclear, especially how background therapy should be interpreted. We aimed to determine preferences in how clinicians caring for SLE patients manage background therapy in patients in clinical remission and to assess how previous severity, duration of remission and serology influences therapy alterations.
Methods: We undertook an internet-based survey of clinicians managing SLE patients. Case scenarios were constructed to reflect different remission states, previous organ involvement, serological abnormalities, duration of remission and current therapy (hydroxychloroquine [HCQ], steroids and/or immunosuppressives [ISS]).
Results: 130 clinicians from 30 countries were surveyed. 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, 113 (86.7%) clinicians continue HCQ. Persistent abnormal serology in any scenario led to a reluctance to reduce or discontinue medications. Prescribing in remission scenarios varied significantly according to geographic location, particularly with regard to steroids and HCQ.
Conclusions:
Clinicians preferences in withdrawing or reducing therapy in SLE patients in clinical remission varies substantially. Serological abnormalities, previous disease severity and duration of remission all influence the decision to reduce treatments. It is unusual for clinicians to withdraw HCQ even after prolonged periods of clinical remission. Any definition(s) of remission need to take into consideration such evidence on how maintenance therapies are managed.