Steroids cause damage accrual in SLE even in patients with no disease activity

The importance of a steroid-sparing approach in SLE has been highlighted by Australian-led research showing that glucocorticoid use contributes to damage accrual independently of disease activity.

An Asia-Pacific region study that followed up 1707 SLE patients for a median of two years found that irreversible organ damage, measured by Systemic Lupus International Collaborating Clinics Damage Index (SDI), was observed in 14·9% of patients overall.

When the researchers looked at the subgroup of patients in whom SLE was inactive (9.2%, according to a time-adjusted mean SLEDAI-2K score of 0 for the entire study period) they found that the proportion of patients who accrued damage was not significantly different (13·4%) to patients with active disease.

In the study, 1405 (82·3%) of patients were exposed to prednisolone, with a mean dose of 5mg/day. The study also showed that damage accrual was independently associated with prednisone dose despite the median dose in these patients being only 2mg/day.

The study investigators, led by Dr Diane Apostolopoulos, from the School of Clinical Sciences at Monash Health, noted an unexpected finding that use of hydroxychloroquine was not protective for damage accrual. They said this might be because the follow-up period could have been too short for a protective effect of antimalarials to be detected

“In the absence of more effective and safer treatments for SLE, glucocorticoid use remains essential in patients with significant disease activity. However, these findings suggest that unnecessary use of glucocorticoids should be avoided in the management of the disease where possible,” they wrote in Lancet Rheumatology.

A linked commentary  article said there were several ways in which glucocorticoid doses could be minimised in SLE while maintaining treatment efficacy.

It recommended increasing the use of methyl-prednisolone pulses and early immunosuppressive drugs in patients with mild to moderate SLE activity.

It also noted that combination therapy with hydroxychloroquine is recommended in EULAR guidelines to be given long-term to all patients with SLE without contraindications, but only 60–70% of patients receive it.

“The fatalistic idea that glucocorticoid toxicity is the price to pay to avoid the consequences of uncontrolled disease activity and achieve SLE remission is no longer acceptable. Through combining treatments and reducing doses of glucocorticoids, managing SLE with substantially fewer glucocorticoid-related side-effects – and without compromising efficacy – is possible,” it concluded.

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