Glucocorticoid Withdrawal Symptoms and Quality of Life in Patients with Systemic Lupus Erythematosus

Background/Objective. Chronic glucocorticoid (GCS) therapy is associated with increased risk of organ damage in systemic lupus erythematosus (SLE). However, discontinuation of low-dose GCS might cause withdrawal symptoms. This study is aimed at identifying GCS withdrawal symptoms and health-related quality of life (HRQoL) among SLE patients. Methods. SLE patients whose prednisolone had been previously withdrawn or taken <5 mg/day were enrolled. Serum morning cortisol levels were collected after 72-hour GCS discontinuation, and low-dose ACTH stimulation test (LDST) was performed. Patient report outcomes (PROs) included SLE-specific quality of life questionnaire (SLEQoL), functional assessment of chronic illness therapy (FACIT), patient health questionnaire (PHQ-9), and Pittsburgh’s sleep quality index (PSQI). Results. Serum morning cortisol of 100 SLE patients was tested. Most patients were female (88%). Seventy-four patients showed remission. The <a:math xmlns:a="http://www.w3.org/1998/Math/MathML" id="M1"> <a:mtext>mean</a:mtext> <a:mo>±</a:mo> <a:mtext>SD</a:mtext> </a:math> of prednisolone was <c:math xmlns:c="http://www.w3.org/1998/Math/MathML" id="M2"> <c:mn>0.73</c:mn> <c:mo>±</c:mo> <c:mn>1.08</c:mn> </c:math> mg/day. Total SLEQoL and FACIT ( <e:math xmlns:e="http://www.w3.org/1998/Math/MathML" id="M3"> <e:mtext>mean</e:mtext> <e:mo>±</e:mo> <e:mtext>SD</e:mtext> </e:math> ) of all patients were <g:math xmlns:g="http://www.w3.org/1998/Math/MathML" id="M4"> <g:mn>67.05</g:mn> <g:mo>±</g:mo> <g:mn>26.15</g:mn> </g:math> and <i:math xmlns:i="http://www.w3.org/1998/Math/MathML" id="M5"> <i:mn>13.7</i:mn> <i:mo>±</i:mo> <i:mn>8.87</i:mn> </i:math> , respectively. Eighteen percent of patients had moderate-severe depressive symptoms, and 49% were poor sleepers. Adrenal function was determined by LDST in only 39 patients; 5 patients (12.8%) were adrenal insufficiency (AI), and 34 patients were normal adrenal function. Compared to normal adrenal function patients, SLE patients with AI had higher proportion of moderate-severe depressive symptom ( <k:math xmlns:k="http://www.w3.org/1998/Math/MathML" id="M6"> <k:mtext>PHQ</k:mtext> <k:mo>−</k:mo> <k:mn>9</k:mn> <k:mo>></k:mo> <k:mn>9</k:mn> </k:math> ), but not statistically significant (40% vs. 20.6%, <m:math xmlns:m="http://www.w3.org/1998/Math/MathML" id="M7"> <m:mi>p</m:mi> <m:mo>=</m:mo> <m:mn>0.34</m:mn> </m:math> ). PROs were comparable between groups. Independent factors associated with SLEQoL were FACIT (adjusted <o:math xmlns:o="http://www.w3.org/1998/Math/MathML" id="M8"> <o:mi>β</o:mi> </o:math> 1.31, 95% CI 0.76, 1.86, <q:math xmlns:q="http://www.w3.org/1998/Math/MathML" id="M9"> <q:mi>p</q:mi> <q:mo><</q:mo> <q:mn>0.001</q:mn> </q:math> ), PHQ-9 (adjusted <s:math xmlns:s="http://www.w3.org/1998/Math/MathML" id="M10"> <s:mi>β</s:mi> </s:math> 5.21, 95% CI 4.32, 6.09, <u:math xmlns:u="http://www.w3.org/1998/Math/MathML" id="M11"> <u:mi>p</u:mi> <u:mo><</u:mo> <u:mn>0.001</u:mn> </u:math> ), and PSQI (adjusted <w:math xmlns:w="http://www.w3.org/1998/Math/MathML" id="M12"> <w:mi>β</w:mi> </w:math> 4.23, 95% CI 3.01, 5.45, <y:math xmlns:y="http://www.w3.org/1998/Math/MathML" id="M13"> <y:mi>p</y:mi> <y:mo><</y:mo> <y:mn>0.001</y:mn> </y:math> ), but not with AI (adjusted <ab:math xmlns:ab="http://www.w3.org/1998/Math/MathML" id="M14"> <ab:mi>β</ab:mi> </ab:math> -5.2, 95% CI -33.26, 22.93, 0.71, <cb:math xmlns:cb="http://www.w3.org/1998/Math/MathML" id="M15"> <cb:mi>p</cb:mi> <cb:mo>=</cb:mo> <cb:mn>0.71</cb:mn> </cb:math> ). Conclusion. SLE patients with previous GCS exposure could experience AI and withdrawal symptoms such as sleep disturbance and depression during discontinuation of low-dose GCS. Fatigue, depression, and poor sleeper were significantly associated with poor SLEQoL.