Nearly two-thirds of children with systemic lupus erythematosus successfully tapered glucocorticoids within the first year without increased flare risk, according to a recent study.

Researchers evaluated whether early glucocorticoid tapering during the first year of juvenile systemic lupus erythematosus is feasible and whether it increases flare risk, while also assessing the impact of achieving childhood lupus low disease activity state.

The team retrospectively reviewed medical charts of 80 children with moderate-to-severe systemic lupus erythematosus (SLE) from three referral centers in Turkey, diagnosed between 2012 and 2022. Eligibility required at least 12 months of follow-up, consistent visit intervals, documented glucocorticoid (GC) tapering schedule, and treatment adherence. Disease activity was assessed using the SLE Disease Activity Index (SLEDAI), with moderate-to-severe disease defined as SLEDAI greater than or equal to 6.

Successful tapering was defined per modified childhood lupus low disease activity state (cLLDAS) criteria as reduction of prednisolone-equivalent GC dose to less than or equal to 7.5 mg/day or less than or equal to 0.15 mg/kg/day at least once during the first year, along with stable immunosuppressant use, no new organ involvement, SLEDAI less than or equal to 4, and absence of major organ system activity. Flares were defined as new or worsening organ system involvement requiring escalation of therapy. “Our modelling, which was corrected for disease activity, revealed that the achievement of the cLLDAS definition for GC treatment did not increase the risk of flares in a similar tapering pattern, which highlights the safety and feasibility of tapering GC to treat-to-target doses,” noted Ozge Baba, MD, of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey, and colleagues.

The mean age at inclusion was 13.8 years; median baseline SLEDAI was 11. Renal involvement was present in 35 of 80 patients (43.8%), proliferative lupus nephritis in 28 (35.0%). Anti-double-stranded DNA antibodies (anti-dsDNA) were positive in 59 (73.8%), and hypocomplementaemia occurred in 69 (86.3%). The initial GC dose averaged 0.94 mg/kg/day, decreasing by month 3 to 0.45 mg/kg/day.

Within the first year, 50 of 80 patients (62.5%) achieved successful GC tapering; 40 (50.0%) attained the target GC dose by month 12. Flares occurred in 23 patients (28.8%) during this period. Successful tapering did not increase the risk of flares, and patients without flares received higher initial GC doses. “The most important clinical intervention for these childhood lupus patients is to aggressively treat their lupus to prevent the damage accrual associated with lupus disease activity,” noted Joan M. Von Feldt, MD, MSEd, Professor of Medicine, Emeritus, Division of Rheumatology, Perelman School of Medicine at the University of Pennsylvania, Editor in Chief, Journal of Clinical Rheumatology, American College of Rheumatology Past President.

At 12 months, 36 patients (45.0%) met cLLDAS criteria. However, achieving cLLDAS was not protective against flares after month 12. “There is a risk of flare as the GCs are tapered, but there are steroid sparing agents that can be initiated early in the course of the disease that can prevent flares,” continued Dr. Von Feldt. Presence of anti-dsDNA antibodies at month 12 substantially increased the odds of flares. “Serologies can be useful in diagnosis, and anti-dsDNA elevations can predict flares, especially in lupus patients with proliferative nephritis,” stated Dr. Von Feldt.

The researchers reported no conflicts of interest.

Source: Lupus Science & Medicine