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Flares after hydroxychloroquine reduction or discontinuation : results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

Almeida-Brasil, Celline C. ; Hanly, John G. ; Urowitz, Murray ; Clarke, Ann Elaine ; Ruiz-Irastorza, Guillermo ; Gordon, Caroline ; Ramsey-Goldman, Rosalind ; Petri, Michelle ; Ginzler, Ellen M. and Wallace, D. J. , et al. (2022) In Annals of the Rheumatic Diseases 81(3). p.370-378
Abstract

OBJECTIVES: To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance. METHODS: We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). 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. 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... (More)

OBJECTIVES: To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance. METHODS: We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). 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. 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. RESULTS: We studied 1460 (90% female) patients initiating HCQ. aHRs for first 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 groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts. CONCLUSIONS: SLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
autoimmune diseases, epidemiology, hydroxychloroquine, systemic lupus erythematosus
in
Annals of the Rheumatic Diseases
volume
81
issue
3
pages
9 pages
publisher
BMJ Publishing Group
external identifiers
  • pmid:34911705
  • scopus:85124635089
ISSN
1468-2060
DOI
10.1136/annrheumdis-2021-221295
language
English
LU publication?
yes
id
da4fb61c-222b-4600-97ad-59488c39bf44
date added to LUP
2022-04-12 14:46:52
date last changed
2022-08-04 23:39:17
@article{da4fb61c-222b-4600-97ad-59488c39bf44,
  abstract     = {{<p>OBJECTIVES: To evaluate systemic lupus erythematosus (SLE) flares following hydroxychloroquine (HCQ) reduction or discontinuation versus HCQ maintenance. METHODS: We analysed prospective data from the Systemic Lupus International Collaborating Clinics (SLICC) cohort, enrolled from 33 sites within 15 months of SLE diagnosis and followed annually (1999-2019). 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. 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. RESULTS: We studied 1460 (90% female) patients initiating HCQ. aHRs for first 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 groups, respectively, versus HCQ maintenance. Patients with low educational level were at particular risk of flaring after HCQ discontinuation (aHR 1.43, 95% CI 1.09 to 1.87). Prednisone use at time-zero was associated with over 1.5-fold increase in flare risk in all HCQ subcohorts. CONCLUSIONS: SLE flare risk was higher after HCQ taper/discontinuation versus HCQ maintenance. Decisions to maintain, reduce or stop HCQ may affect specific subgroups differently, including those on prednisone and/or with low education. Further study of special groups (eg, seniors) may be helpful.</p>}},
  author       = {{Almeida-Brasil, Celline C. and Hanly, John G. and Urowitz, Murray and Clarke, Ann Elaine and Ruiz-Irastorza, Guillermo and Gordon, Caroline and Ramsey-Goldman, Rosalind and Petri, Michelle and Ginzler, Ellen M. and Wallace, D. J. and Bae, Sang Cheol and Romero-Diaz, Juanita and Dooley, Mary Anne and Peschken, Christine and Isenberg, David and Rahman, Anisur and Manzi, Susan and Jacobsen, Søren and Lim, Sam and van Vollenhoven, Ronald F. and Nived, Ola and Jönsen, Andreas and Kamen, Diane L. and Aranow, Cynthia and Sanchez-Guerrero, Jorge and Gladman, Dafna D. and Fortin, Paul R. and Alarcón, Graciela S. and Merrill, Joan T. and Kalunian, Kenneth and Ramos-Casals, Manuel and Steinsson, Kristján and Zoma, Asad and Askanase, Anca and Khamashta, Munther A. and Bruce, Ian N. and Inanc, Murat and Abrahamowicz, Michal and Bernatsky, Sasha}},
  issn         = {{1468-2060}},
  keywords     = {{autoimmune diseases; epidemiology; hydroxychloroquine; systemic lupus erythematosus}},
  language     = {{eng}},
  number       = {{3}},
  pages        = {{370--378}},
  publisher    = {{BMJ Publishing Group}},
  series       = {{Annals of the Rheumatic Diseases}},
  title        = {{Flares after hydroxychloroquine reduction or discontinuation : results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort}},
  url          = {{http://dx.doi.org/10.1136/annrheumdis-2021-221295}},
  doi          = {{10.1136/annrheumdis-2021-221295}},
  volume       = {{81}},
  year         = {{2022}},
}