Stopping Immunotherapy Possible in Some Patients With Lupus

Alice Goodman

June 15, 2014

PARIS ― Some patients with systemic lupus erythematosus who are in clinical remission with immunosuppressant therapy may be able to stop therapy without triggering a new disease flare, according to the results of a new retrospective study.

"Immunosuppressive agents are very important in the management of lupus, but they do have side effects. At present, there are no guidelines on how or when to stop immunosuppressant therapy ― it is up to the individual physician," said study author Zahi Touma, MD, from the Division of Rheumatology at the University of Toronto, Canada.

"Our results confirm that stopping immunosuppressants is possible in a selected group of patients," he added.

The retrospective study was presented here at the European League Against Rheumatism (EULAR) Congress 2014.

Tapering Immunosuppressants

Dr. Touma and his colleagues looked at data from 179 patients registered at the Toronto Lupus Clinic between 1970 and 2012 who had been prescribed an immunosuppressant (azathioprine, methotrexate, or mycophenolate mofetil [CellCept, Roche]) and had attempted to taper off their medication.

All patients included in the study had tapered their immunosuppressant therapy by at least 25%; were in clinical remission, determined on the basis of having no disease activity, as measured using the Systemic Lupus Erythematosus Disease Activity Index; and were taking less than 7.5 mg of prednisone per day. Mean age at tapering was 40.4 years, and mean disease duration was 11.4 years.

Data for each patient were gathered at 3 time points: initiation of tapering; the date the immunosuppressant was completely stopped; and end of study. Flare was defined as introduction of a new immunosuppressant or any increase in prednisone dosage in patients with clinically active lupus.

A total of 99 patients (56%) were able to stop immunosuppressant therapy completely. Of these, 74% had no disease flares within 2 years, and 50% had no flare within 3 years and remained stable for up to 5 years.

A higher percentage of patients who experienced disease flare within 2 years of stopping their immunosuppressant had positive serology, indicating the presence of specific antibodies for lupus, compared with those who did not experience flare within this period.

"The rate of flare after stopping immunotherapy was lower in the group of patients who tapered gradually," said Dr. Touma, suggesting that this is the best approach to discontinuing therapy.

"This study is a milestone in lupus treatment. We know how to start medications, but only a few studies have addressed how and when to stop," said Ulf Müller-Ladner, MD, chair of the Department of Rheumatology at the University of Giessen in Germany and chair of the EULAR scientific program.

"The key messages are that we can stop, but we have to be careful. Not every patient can stop, and we have to know who the candidates [for stopping] are," he said. "Patients should be closely monitored after they stop immunosuppressant therapy."

Dr. Touma and Dr. Müller-Ladner have disclosed no relevant financial relationships.

European League Against Arthritis (EULAR) Congress 2014: Abstract OP0042. Presented June 12, 2014.


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