Low-dose glucocorticoid should be withdrawn or continued in systemic lupus erythematosus? A systematic review and meta-analysis on risk of flare and damage accrual

Low-dose glucocorticoid should be withdrawn or continued in systemic lupus erythematosus? A systematic review and meta-analysis on risk of flare and damage accrual

Objective: To assess the risk of flare and damage accrual after low dose glucocorticoids (GC) discontinuation in systemic lupus erythematosus (SLE).

Methods: We performed a comprehensive literature search of PubMed, EMBASE, Cochrane library and Scopus databases from inception to July 2020 for studies concerning relapses/damage accrual in SLE patients. Pooled incidence rates of flare and time to flare with their 95% confidence intervals (CI) after GC withdrawal were calculated. Summary risk ratio (RR) and 95% CI of flare/organ damage accrual risk were computed using a random or fixed effects model.

Results: 738 SLE patients with GC discontinuation in 17 publications were eligible for the final analysis. In the primary meta-analysis, the pooled incidence of flare was 24% (95% CI 21-27%) and 13% (95% CI 8-18%) for global and major flare respectively. Pooled time to flare was 21.08 (95% CI 9.32-32.85) months. In the secondary meta-analysis, GC discontinuation showed an increased risk of flare comparing with GC continuation [RR (95% CI) =1.38 (1.01-1.89)], but the risk of major flares was not increased (RR = 1.77, 95% CI 0.40-7.83). Moreover, GC withdrawal was associated with a borderline reduction of risk in SDI increase in comparison with GC continuation (RR = 0.64, 95% CI 0.38 - 1.09).

Conclusion: GC discontinuation leads to a slightly increased risk of flare, however no increase in major flare and a borderline reduction of risk in further damage in SLE patients. Baseline screening for candidate patients and long-term follow up after GC withdrawal are needed to reliably evaluate the organ damage increase.


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