Treatment pathways in an inception lupus cohort over the first three years

Abstract

Objective The treatment algorithm for new onset systemic lupus erythematosus (SLE) is less well defined than for other rheumatic diseases. We examined the treatment patterns in an inception cohort of SLE patients over the first three years of disease between 2000 and 2010. Methods Patients fulfilled the American College of Rheumatology classification criteria for SLE within 12 months of enrollment and completed three subsequent annual visits. Data collection included patient demographics, SLE manifestations, medications, SLE disease activity index-2K (SLEDAI-2K) and Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index. Analysis included descriptive statistics and repeated measures mixed models. Results Seventy-nine patients, 83.5% female and 91.1% Caucasian were studied. At baseline the mean (SD) age was 40.6 (16.4) years, disease duration was 0.36 (0.28) years and SLEDAI-2K was 5.7 (4.6). Over three years, cumulative use of corticosteroids, antimalarials and immunosuppressants was 53.2%, 77.2% and 40.5% respectively. Corticosteroids were usually used in combination with antimalarials and/or immunosuppressants. Between baseline and final assessments the use of corticosteroids fell (44.3% vs 15.2%) in contrast to antimalarials (55.7% vs 70.9%) and immunosuppressants (26.6% vs 34.2%). Of 44/79 (55.7%) patients not receiving corticosteroids at baseline 84.1% remained off corticosteroids for the study duration. Thirty-seven of 79 (46.8%) patients never received corticosteroids and only 5/79 (6.3%) at all four assessments. Patients taking corticosteroids at baseline had higher mean (SD) daily dose and cumulative dose over three years compared with patients not on corticosteroids at baseline (9.0 (0.8) vs 0.3 (1.3) mg; 10.8 (8.5) vs 0.3 (1.2) g). As a group, SLE patients who used corticosteroids either at baseline, at any time in the three year study or in high cumulative doses had the highest average disease activity scores over the same time frame and had a significant fall in SLEDAI-2K scores ( p < 0.05) compared with patients not exposed to corticosteroids. Conclusion Use of corticosteroids occurred in approximately half of new onset SLE, usually in combination with antimalarials and/or immunosuppressants. It was associated with both higher disease activity at baseline and improvement over time. Patients who did not receive corticosteroids at presentation were unlikely to do so over the next three years.