Some Lupus Patients Can Safely Stop Immunosuppressants: Study

By Megan Brooks

NEW YORK - Most patients with systemic lupus erythematosus who are in remission can stop immunosuppressant therapy without triggering a flare up, clinicians from Toronto have found.

In their experience, within two years, it was possible to stop immunosuppressant therapy in about 70% of clinically stable patients; roughly half were still flare-free at three years, and this proportion remained stable for up to five years.

"It is reassuring to know that you can stop immunosuppressants in a selected group of patients," Dr. Zahi Touma, Assistant Professor of Medicine, Clinician-Scientist, Division of Rheumatology, at the University of Toronto, told Reuters Health.

Lupus is a chronic inflammatory disease which typically follows a relapsing-remitting course and often requires long term immunosuppressant therapy. Being able to stop long-term immunosuppressant therapy without inducing a relapse is an important treatment goal.

"Until now, information on whether and how immunosuppressant therapy might be stopped in lupus patients after achieving low disease activity or remission has been limited," Dr. Touma explains in a statement from the European League Against Rheumatism (EULAR) 2014 Annual Congress in Paris, where he presented his research.

"The results from our study provide useful guidance on how best to stop the immunosuppressant without triggering a flare. For example, patients who discontinued their immunosuppressant more slowly were less likely to flare within two years. Those lupus patients who were serologically active at the time the immunosuppressant was stopped were much more likely to flare on follow-up visits," he said.

Among 973 patients from the Toronto Lupus Clinic, 99 tapered and then stopped their immunosuppressant. Fifty-six had been on azathioprine, 25 had been on methotrexate, and 18 had been taking mycophenolate mofetil.

All patients who stopped treatment were in clinical remission, defined as no disease activity in the clinical SLE Disease Activity Index-2000 (SLEDAI-2K), absence of proteinuria or lupus-related thrombocytopenia and leukopenia, and taking less than 7.5 mg of prednisone per day. Their average age at tapering was 40 years, and average disease duration was 11 years.

Of the 99 patients who stopped their immunosuppressant, 25 experienced a flare within two years and 17 patients experienced a flare after two years.

A higher percentage of patients who experienced disease flare within two years of stopping their immunosuppressant had positive serology (lupus-specific antibodies), compared with those who did not have a flare within two years (68% vs 42%, p=0.04).

Disease flare was defined as the introduction of a new immunosuppressant, or any increase of prednisone dosage in the context of clinically active lupus.

"The percentage of patients who flared was less with slow taper," Dr. Touma told Reuters Health. In patients who didn't flare, the length of time from the start of tapering to stopping the immunosuppressant was 1.8 years, significantly longer than the 0.9 years in the group who did experience a flare (p=0.002).

Dr. Touma said that based on this study, candidates for stopping immunosuppressant therapy are "patients who have no disease activity for at least one year and on no prednisone or a low-dose of prednisone, which in this study was defined at 7.5 mg per day or less. And the outcome is better if you do the taper slowly. Take your time tapering the immunosuppressant, don't stop it right away," he advised.

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