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

Research output: Contribution to journalJournal articleResearchpeer-review

  • Celline C Almeida-Brasil
  • John G Hanly
  • Murray Urowitz
  • Ann Elaine Clarke
  • Guillermo Ruiz-Irastorza
  • Caroline Gordon
  • Rosalind Ramsey-Goldman
  • Michelle Petri
  • Ellen M Ginzler
  • D J Wallace
  • Sang-Cheol Bae
  • Juanita Romero-Diaz
  • Mary Anne Dooley
  • Christine Peschken
  • David Isenberg
  • Anisur Rahman
  • Susan Manzi
  • Søren Jacobsen
  • Sam Lim
  • Ronald F van Vollenhoven
  • Ola Nived
  • Andreas Jönsen
  • Diane L Kamen
  • Cynthia Aranow
  • Jorge Sanchez-Guerrero
  • Dafna D Gladman
  • Paul R Fortin
  • Graciela S Alarcón
  • Joan T Merrill
  • Kenneth Kalunian
  • Manuel Ramos-Casals
  • Kristján Steinsson
  • Asad Zoma
  • Anca Askanase
  • Munther A Khamashta
  • Ian N Bruce
  • Murat Inanc
  • Michal Abrahamowicz
  • Sasha Bernatsky
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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.

Original languageEnglish
JournalAnnals of the Rheumatic Diseases
Issue number3
Pages (from-to)370-378
Number of pages9
Publication statusPublished - Mar 2022

Bibliographical note

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

    Research areas

  • systemic lupus erythematosus, hydroxychloroquine, autoimmune diseases, epidemiology

ID: 73990010