Glucocorticoid, immunosuppressant, hydroxychloroquine monotherapy, or no therapy for maintenance treatment in systemic lupus erythematosus without major organ manifestations

  • Hironari HanaokaEmail author
  • Harunobu Iida
  • Tomofumi Kiyokawa
  • Yukiko Takakuwa
  • Kimito Kawahata
Original Article



To study maintenance therapy after achievement of the lowest possible disease activity in systemic lupus erythematosus (SLE) without major organ manifestations.


We retrospectively evaluated patients with SLE who visited our hospital from Jan 2015 to Feb 2018 and were taking prednisolone (PSL) < 10 mg/day. After excluding those with neuropsychiatric SLE or severe lupus nephritis, patients were divided into four groups according to their maintenance monotherapy treatment, namely, prednisolone (PSL), immunosuppressant (IS), hydroxychloroquine (HCQ), and no drugs. The groups were then compared with regard to cumulative flare rate and changes in SLE Disease Activity Index (SLEDAI).


There were 47 patients on PSL, 10 on IS, 5 on HCQ, and 11 on no drugs. Flare rate was higher in the no drug group, and no patients with the IS or HCQ group experienced a flare (p = 0.003). A reduction in SLEDAI was only seen in the IS and HCQ groups (p = 0.05 and p = 0.03, respectively). There were no differences in adverse events among groups during the study period.


Our results suggest that the cessation of all drugs is associated with disease flare for SLE patients without major organ manifestations. IS or HCQ monotherapy might be a reasonable maintenance strategy comparing with steroid monotherapy.

Key Point

Immunosuppressant or hydroxychloroquine monotherapy appears to be a reasonable maintenance strategy.


Hydroxychloroquine Immunosuppressive agents Relapse Systemic lupus erythematosus 


Compliance with ethical standards

This study was approved by the Ethics Committee of St. Marianna University School of Medicine (approval number 3305).




  1. 1.
    Gordon C, Amissah-Arthur MB, Gayed M, Brown S, Bruce IN, D’Cruz D, Empson B, Griffiths B, Jayne D, Khamashta M, Lightstone L, Norton P, Norton Y, Schreiber K, Isenberg D, British Society for Rheumatology Standards, Audit and Guidelines Working Group (2018) The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults: executive summary. Rheumatology (Oxford) 57:14–18CrossRefGoogle Scholar
  2. 2.
    van Vollenhoven RF, Mosca M, Bertsias G, Isenberg D, Kuhn A, Lerstrøm K, Aringer M, Bootsma H, Boumpas D, Bruce IN, Cervera R, Clarke A, Costedoat-Chalumeau N, Czirják L, Derksen R, Dörner T, Gordon C, Graninger W, Houssiau F, Inanc M, Jacobsen S, Jayne D, Jedryka-Goral A, Levitsky A, Levy R, Mariette X, Morand E, Navarra S, Neumann I, Rahman A, Rovensky J, Smolen J, Vasconcelos C, Voskuyl A, Voss A, Zakharova H, Zoma A, Schneider M (2014) Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis 73:958–967CrossRefGoogle Scholar
  3. 3.
    The Canadian Hydroxychloroquine Study Group (1991) A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus. N Engl J Med 324:150–154CrossRefGoogle Scholar
  4. 4.
    Wilhelm TR, Magder LS, Petri M (2017) Remission in systemic lupus erythematosus: durable remission is rare. Ann Rheum Dis 76:547–553CrossRefGoogle Scholar
  5. 5.
    van Vollenhoven R, Voskuyl A, Bertsias G, Aranow C, Aringer M, Arnaud L, Askanase A, Balážová P, Bonfa E, Bootsma H, Boumpas D, Bruce I, Cervera R, Clarke A, Coney C, Costedoat-Chalumeau N, Czirják L, Derksen R, Doria A, Dörner T, Fischer-Betz R, Fritsch-Stork R, Gordon C, Graninger W, Györi N, Houssiau F, Isenberg D, Jacobsen S, Jayne D, Kuhn A, Le Guern V, Lerstrøm K, Levy R, Machado-Ribeiro F, Mariette X, Missaykeh J, Morand E, Mosca M, Inanc M, Navarra S, Neumann I, Olesinska M, Petri M, Rahman A, Rekvig OP, Rovensky J, Shoenfeld Y, Smolen J, Tincani A, Urowitz M, van Leeuw B, Vasconcelos C, Voss A, Werth VP, Zakharova H, Zoma A, Schneider M, Ward M (2017) A framework for remission in SLE: consensus findings from a large international task force on definitions of remission in SLE (DORIS). Ann Rheum Dis 76:554–551CrossRefGoogle Scholar
  6. 6.
    Zahr ZA, Fang H, Magder LS, Petri M (2013) Predictors of corticosteroid tapering in SLE patients: the Hopkins lupus cohort. Lupus 22:697–701CrossRefGoogle Scholar
  7. 7.
    Mosca M, Tani C, Aringer M (2013) Withdrawal of therapy in non-renal systemic lupus erythematosus: is this an achievable goal? Clin Exp Rheumatol 31:S71–S74Google Scholar
  8. 8.
    Hochberg MC (1997) Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 40:1725CrossRefGoogle Scholar
  9. 9.
    The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes (1999) Arthritis Rheum 42:599–608CrossRefGoogle Scholar
  10. 10.
    Weening JJ, D'Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, Hill P, Jennette JC, Kong NC, Lesavre P, Lockshin M, Looi LM, Makino H, Moura LA, Nagata M (2004) The classification of glomerulonephritis in systemic lupus erythematosus revised. J Am Soc Nephrol 15:241–250CrossRefGoogle Scholar
  11. 11.
    Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH (1992) Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis Rheum 35:630–640CrossRefGoogle Scholar
  12. 12.
    Petri M, Buyon J, Kim M (1999) Classification and definition of major flares in SLE clinical trials. Lupus 8:685–691CrossRefGoogle Scholar
  13. 13.
    Galbraith L, Manns B, Hemmelgarn B, Walsh M (2014) The steroids in the maintenance of remission of proliferative lupus nephritis (SIMPL) pilot trial. Can J Kidney Health Dis 1:30CrossRefGoogle Scholar
  14. 14.
    Drenkard C, Villa AR, Garcia-Padilla C, Pérez-Vázquez ME, Alarcón-Segovia D (1996) Remission of systematic lupus erythematosus. Medicine (Baltimore) 75:88–98CrossRefGoogle Scholar
  15. 15.
    Pons-Estel BA, Catoggio LJ, Cardiel MH, Grupo Latinoamericano de Estudio del Lupus et al (2004) The GLADEL multinational Latin American prospective inception cohort of 1,214 patients with systemic lupus erythematosus: ethnic and disease heterogeneity among “Hispanics”. Medicine (Baltimore) 83:1–17CrossRefGoogle Scholar
  16. 16.
    Steiman AJ, Urowitz MB, Ibañez D, Papneja A, Gladman DD (2014) Prolonged clinical remission in patients with systemic lupus erythematosus. J Rheumatol 41:1808–1816CrossRefGoogle Scholar
  17. 17.
    Zen M, Iaccarino L, Gatto M, Bettio S, Nalotto L, Ghirardello A, Punzi L, Doria A (2015) Prolonged remission in Caucasian patients with SLE: prevalence and outcomes. Ann Rheum Dis 74:2117–2122CrossRefGoogle Scholar

Copyright information

© International League of Associations for Rheumatology (ILAR) 2019

Authors and Affiliations

  1. 1.Division of Rheumatology and Allergology, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan

Personalised recommendations