Preventing chronic damage accrual is one of the top treatment targets, as it is linked to increased mortality and decreased quality of life.
Even in patients with systemic lupus erythematosus (SLE) with long disease duration, 1-point glucocorticoid (GC)-free treatment status may be linked to no chronic damage increase, according to a study published in Lupus Science & Medicine.1
“GCs are still the mainstay of treatment for SLE,” investigators stated. “Owing to the contribution of several novel therapeutic agents, the treat-to-target principle has been established to care for patients with SLE… The prevention of chronic damage accrual has become one of the topmost current treatment targets, next to decreasing mortality. The accumulation of chronic damage is associated with increased mortality, and with reduced quality of life.”
Data from the lupus registry of nationwide institutions (LUNA), conducted in 2016, were used to compare a GC dose at registration and short (<5 years), middle (5-20 years), and long (≥20 years) disease durations. Patients enrolled in LUNA were aged 20 years or older and had been clinically diagnosed with SLE according to the revised 1997 American College of Rheumatology criteria for SLE classification. Those who never used GCs were excluded from the study. Data obtained included age, sex, disease duration, hydroxychloroquine and immunosuppressant use, prednisone dose, serum creatine level, complement (C3, C4, CH50) level, and SLE Disease Activity Index 200 (SLEDAI-2K). The relationship between GC-free status and chronic damage was assessed using the Systemic Lupus International Collaborating Clinics Damage Index (SLICC-DI).
Of the 1019 patients included in the study, the median age was 45 years, median disease duration was 12 years, median SLEDAI score at registration was 4, and 88% (n = 895) were female. In total, 101 (10%) were GC-Free (10%), 411 (40%) reported 0< prednisolone (PSL) ≤5 mg/day, 169 (17%) reported 5< PSL ≤7.5, 194 (19%) reported 7.5< PSL ≤10, and 144 (14%) received PSL≥10. In patients who were GC-free. Those who had were not currently being treated with GCs were more likely to report shorter disease duration (66% [n = 21/32] with short disease duration, 23% [n = 7/30] with middle disease duration, and 17% [n = 3/18] with long disease duration p=0.00029).
A univariate analysis of those who received GC-treatment reported that patients without GCs exhibited lower disease activity, were older, reported less immunosuppressant and hydroxychloroquine use, and had higher C3 levels. For those with a disease duration of ≥ 20 years, GC-free status was seen more frequently in patients without chronic damage (11% vs 4%, p=0.023, respectively). No chronic damage accrual was associated with GC-free status after adjusting for the confounding factors of age, sex, and SLEDAI-2K (odds ration [OR] 3.6, 95% CI 1.1 to 11.3).
The cross-sectional nature of the study design prevented investigators from determining conclusions based on the GC-treatment and free period and a patient’s cumulative dose. Further, the limited number of patients with long disease duration may not be sufficient for a multivariate analysis.
“Since the patients without GC might include the patients with high cumulative GC dose, the relationship between achievement of GC and chronic damage might be underestimated,” investigators concluded. “Nevertheless, at least one-point GC-free treatment status was statistically related to no damage accrual in the patients with a longer disease duration. Therefore, it might be important to achieve the GC-free treatment status even in the patients with long disease duration.”
Sada KE, Katayama Y, Asano Y, et al. Association of one-point glucocorticoid-free status with chronic damage and disease duration in systemic lupus erythematosus: a cross-sectional study. Lupus Sci Med. 2022;9(1):e000772. doi:10.1136/lupus-2022-000772