Immunosuppressive therapy withdrawal is safe in patients with lupus nephritis (LN) who have achieved a long, stable remission, according to investigators.
Among 513 patients with systemic lupus erythematosus (SLE), 270 had LN. Of these, 238 were treated with immunosuppressive therapy. After 46 months, 83 patients (34.8%) who were in remission (defined as normal serum creatinine, proteinuria less than 0.5 g/24h, inactive urine sediment, and no extra-renal SLE activity) with stable immunosuppressive therapies, antimalarials, and/or low-dose prednisone (5 mg/d or less) discontinued their immunosuppressants. Most patients received hydroxychloroquine thereafter.
Only 19 patients (22.8%) experienced a flare after halting immunosuppressants over a mean 116.5 months, Andrea Doria, MD, of the University of Padova in Padua, Italy, and colleagues reported in Rheumatology. Fourteen of the 19 patients (73.7%) re-achieved remission after they restarted immunosuppressive therapy.
Patients treated with immunosuppressive therapy for at least 3 years after achieving remission had significant 72% decreased odds of relapse compared with patients with shorter remission times. On multivariate analysis, use of antimalarials, age at discontinuation of immunosuppressant therapies, and remission longer than 3 years significantly correlated with 81%, 7%, and 77% decreased odds of LN flare, the investigators reported.
Younger age at immunosuppressant discontinuation, no maintenance hydroxychloroquine, and class 4 LN at first biopsy, were associated with increased odds of flare.
Immunosuppressive therapy should be maintained for at least 3 years after achieving remission to minimize the risk of relapses, according to Dr Doria’s team. After therapy withdrawal, clinicians should perform regular surveillance to allow early detection and prompt treatment of relapse, they stated. Antimalarial therapy was protective against disease flare after immunosuppressant discontinuation, so the investigators advised long-term therapy with antimalarials unless contraindicated.
Margherita Z, Enrico F, Martinez Marta L, et al. Immunosuppressive therapy withdrawal after remission achievement in patients with lupus nephritis: Prognosis of patients with lupus nephritis after immunosuppressant discontinuation. Rheumatology. Published online April 28, 2021. doi:10.1093/rheumatology/keab373