Study on Antimalarial Withdrawal and Lupus Flare

Slow withdrawal from antimalarial medication after at least 1 year of remission does not increase the risk of a lupus flare, suggest a study presented on ACR Convergence 2020. The study details were published in the Arthritis and Rheumatology.

Antimalarials are believed to be effective in controlling lesions of the skin and mucous membranes, as well as the malaise, easy fatigability, arthritis, and pleuritic pain of systemic lupus erythematosus. However, little is known about the effects of AM withdrawal in patients who have achieved prolonged disease quiescence. For this purpose, the researchers investigated the rate of flare in lupus patients who withdrew their AM after achieving clinical remission for at least one year, compared to those who continued therapy. They also compared the flare rates in patients who tapered AM with the patients who abruptly withdrew it.

It was a retrospective analysis of patients database on antimalarial medication from the Lupus Clinic long-term observational cohort study. They determined the date of complete AM cessation as the Index date. Patients who achieved clinical remission for at least one year then ceased their AM were considered as the intervention group and patients who achieved clinical remission for at least one year and continued AM were considered as a control group. Among 261 patients with the data of at least 2 years of follow-up, 88 were enrolled in the intervention group and 173 were enrolled in the control group.

Key Findings of the Study

• Disease flare occurred at a high rate in the intervention group (withdrew AM) of about 61.4% when compared with the control group (continued AM) of about 45.1%. Researchers observed the most common types of flare were skin and musculoskeletal flares. Retinal toxicity occurred in 1.9% of patients.
• They noted over half of the patients who withdrew AM later restarted it, typically due to disease flare and on the recommencement of AM most patients (88%) recaptured control or improved, while 12% had further flares.
• They found among patients who withdrew AM, 42% tapered and 58% ceased abruptly.
• They also found the median duration (months) spent on AM from one year after clinical remission to cessation was expectedly longer in the taper group (29.2 months) compared to the abrupt withdrawal group (11.2 months).
• They reported that the patients who tapered had significantly fewer flares (45.9%), similar to the rate for controls (45.1%) when compared to those who withdrew abruptly (72.6%).
• They also noted fewer patients in the taper group restarted AM following cessation (37.8%) compared to the abrupt withdrawal group (62.7%).

The authors conclude, "For those who withdraw therapy, tapering results in lower rates of disease flare, similar to those seen in patients who continue AMs. Hence, except in the setting of toxicity, cessation of antimalarial therapy in patients with prolonged disease quiescence is feasible using a slow taper".

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