SLE Disease Flare Less Likely With HCQ Maintenance

Investigators recently found that the risk of a systemic lupus erythematosus (SLE) flare was higher following a taper or discontinuation of hydroxychloroquine (HCQ) compared to HCQ maintenance, even in patients with low disease activity or remission.

Patients and physicians often consider reducing or discontinuing HCQ to limit cumulative exposure and avoid HCQ-induced toxicity. There has been conflicting information about whether HCQ reduction/withdrawal is safe in stable patients or is associated with disease flares, and if there is a subgroup of patients among whom it would be safe to stop or reduce HCQ.

This study aimed to evaluate SLE flares following HCQ reduction or discontinuation versus HCQ maintenance, as well as determine any predictors of a flare once HCQ has been reduced or discontinued. Using prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, the researchers included 1460 patients (90% female) initiating HCQ from 33 sites within 15 months of SLE diagnosis and followed them annually during the period 1999 to 2019. Of those patients, 592 (564 matched to 778 patients maintaining HCQ) reduced HCQ and 407 (389 matched to 577 patients maintaining HCQ) discontinued HCQ.

“We evaluated person-time contributed while on the initial HCQ dose ('maintenance'), comparing this with person-time contributed after a first dose reduction, and after a first HCQ discontinuation,” the authors wrote. “We estimated time to first flare, defined as either subsequent need for therapy augmentation, increase of ≥4 points in the SLE Disease Activity Index-2000, or hospitalisation for SLE. We estimated adjusted HRs (aHRs) with 95% CIs associated with reducing/discontinuing HCQ (vs maintenance). We also conducted separate multivariable hazard regressions in each HCQ subcohort to identify factors associated with flare.”

The researchers wrote, “Compared with HCQ maintenance, the adjusted HRs for SLE flare were 1.20 (95% CI 1.04 to 1.38) and 1.56 (95% CI 1.31 to 1.86) for the HCQ reduction and discontinuation cohorts, respectively. The mean doses of those reducing HCQ and flaring versus those reducing but not flaring were similar.”

There was also a higher risk of SLE flares associated with use of prednisone and immunosuppressives in all cohorts. Among those who discontinued HCQ, there was an increased risk of SLE flare associated with lower education.

These results emphasize the ongoing need to optimize therapeutic options in SLE, the authors concluded.

—Allison Casey

Reference:
Almeida-Brasil CC, Clark AE, Gordon C, et al. Flares after hydroxychloroquine reduction or discontinuation: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. Ann Rheum Dis. Published online first: December 15, 2021. doi: 10.1136/annrheumdis-2021-221295