During today’s plenary session at CRA 2015, Dr. Zahi Touma presented data on the successful withdrawal and discontinuation of immunosuppressants in lupus patients.
After achieving a low disease activity or remission in lupus, can we stop immunosuppressants? If we stop immunosuppressants, will it trigger a flare? Are there any predictors of successful discontinuation of immunosuppressants?
The study that examined these questions was a retrospective analysis of data from the Toronto Lupus Cohort spanning the years from 1970 to 2012. The activity of lupus was determined using the SLEDAI-2K.
All patients in the study were require to be in clinical remission defined by no activity in the clinical SLEDAI-2K descriptors. All patients needed to taper and ultimately stop immunosuppressants due to low disease activity and not due to side effects. Finally, patients must have been on a low dose of prednisone, defined as 7.5 mg per day or less.
The outcome measure was a clinical flare associated with the start of or any increase in either immunosuppressants or prednisone. This endpoint was measured at 2 years following discontinuation of IS.
The Toronto Lupus Cohort has 1678 registered patients. Of these, 978 had ever taken an immunosuppressant. Of these 978, 179 had tried to taper immunosuppressants with a total of 99 ultimately successful in stopping their IS. The 99 patients who had successfully stopped immunosuppressants were included in this study.
Among the patients who stopped immunosuppressants, 91% were female, the mean duration of lupus was 11.4 +/- 9.4 years, and the average age was about 40 years.
Out of 99 who discontinued immunosuppressants at year 2:
Did not flare - 74 (75%)
Flared - 25 (25%)
The time to discontinue immunosuppressants was inversely proportional to the chance of flare. If the immunosuppressants were tapered very slowly, then the chances of flare were lower.
Of the 74 who initially did not flare, over the next 2 years 17 did.
In conclusion, within 2 years, 75% of patients were able to stop immunosuppressants without a flare of lupus. Within 5 years, 50% of patients remained off immunosuppressant without a flare of lupus.