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Archive of Annals of the Rheumatic Diseases, a leading rheumatology journal previously published by BMJ.

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Objective Glucocorticoid (GC) tapering and withdrawal to reduce damage represents a key aspect of the European Alliance of Associations for Rheumatology (EULAR) SLE recommendations. However, optimal strategies for relapse-free GC cessation remain ill-defined. We characterised clinical predictors and their combined effect on flares in patients with SLE who discontinued GC.Methods Retrospective cohort of 324 patients with active SLE (PGA ≥1.5 and/or SLEDAI-2K ≥6) who received GC as part of treatment intensification (median follow-up 60 months). Survival and generalised linear models estimated SELENA-SLEDAI flare risks and their predictors.Results GCs were discontinued in 220 (67.9%) patients with 1-year risks for overall and severe flares of 50% and 25%, respectively (HR: 1.48; 95% CI: 1.12 to 1.96 for overall flares; HR: 1.52; 95% CI: 1.03 to 2.25 for severe flares, compared with non-withdrawers). Flare risk was lowered when GCs were ceased during remission (DORIS) or Lupus Low Disease Activity State (LLDAS; excluding remission) (HR for severe flares: 0.23; 0.12 to 0.43 and 0.30; 0.18 to 0.50, respectively), with each additional month in targets providing further protection. Hydroxychloroquine prevented total (HR: 0.37; 0.26 to 0.53) and severe flares (HR: 0.33; 0.21 to 0.52), while mycophenolate and azathioprine reduced overall flares. Prednisone tapering from 7.5 mg/day to 0 over >6 months improved severe flare-free outcome (HR: 0.57; 0.37 to 0.90). Random survival forests identified DORIS/LLDAS, hydroxychloroquine use and slow GC tapering as top predictors, whose coexistence reduced overall and severe flares by ~25 fold and ~50 fold, respectively. This combination reduced damage (IRR: 0.31; 0.08 to 0.84) without inducing flares (IRR: 0.52; 95% CI: 0.18 to 1.16) compared with GC non-withdrawers.Conclusion Low or absent disease activity, slow tapering and hydroxychloroquine use minimise the risk of flares, facilitating GC discontinuation—a major goal in SLE.

lupus.bmj.com

Objective To evaluate the feasibility, usability and acceptability of implementing a treat-to-target (T2T) strategy supported by a Clinical Decision Support System (CDSS), in routine SLE outpatient care.Methods A 24-week, non-randomised, multicentre, clustered pilot study was conducted across four rheumatology outpatient centres. Adult patients with SLE were allocated by centre to either a T2T strategy supported by a CDSS (T2T-CDSS) or a routine outpatient care (ROC) group. The CDSS provided evidence-based treatment recommendations based on disease activity measures. Feasibility outcomes included recruitment and retention rates. Usability was assessed with the System Usability Scale (SUS), completed by physicians in the T2T-CDSS group. Acceptability was evaluated using the Treatment Satisfaction Questionnaire (TSQ) and qualitative feedback. Exploratory outcomes included disease activity, remission rates and treatment modifications.Results Of 91 screened patients, 38 were enrolled (recruitment rate 42%) and 35 completed the study (retention rate 92%). The SUS score for the CDSS was 73.8, indicating good usability. Global satisfaction scores on the TSQ were stable over time and comparable between groups. Remission was achieved at least once by 61% (11/18) of patients in the T2T-CDSS group and 59% (10/17) in the ROC group. Both treatment intensifications and de-escalations occurred more frequently in the T2T-CDSS group compared with ROC (83% vs 47%). Treatment intensifications were observed in 61% of patients in the T2T-CDSS group vs 29% in the ROC group. Treatment de-escalation, represented by glucocorticoid tapering, occurred in 39% of T2T-CDSS patients compared with 18% in ROC. No statistically significant differences were observed between groups in disease activity outcomes or remission rates.Conclusions Implementation of a T2T strategy supported by a CDSS in SLE outpatient care was feasible, usable and acceptable to patients and physicians. Although qualitative fe

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