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

Abstract

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 SLE patients whose prednisolone had been previously withdrawn or taken 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 $\text{mean}\pm \text{SD}$ of prednisolone was $0.73\pm 1.08$ mg/day. Total SLEQoL and FACIT ( $\text{mean}\pm \text{SD}$ ) of all patients were $67.05\pm 26.15$ and $13.7\pm 8.87$ , 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 ( $\text{PHQ}-9>9$ ), but not statistically significant (40% vs. 20.6%, $p=0.34$ ). PROs were comparable between groups. Independent factors associated with SLEQoL were FACIT (adjusted $\beta$ 1.31, 95% CI 0.76, 1.86, $p<0.001$ ), PHQ-9 (adjusted $\beta$ 5.21, 95% CI 4.32, 6.09, $p<0.001$ ), and PSQI (adjusted $\beta$ 4.23, 95% CI 3.01, 5.45, $p<0.001$ ), but not with AI (adjusted $\beta$ -5.2, 95% CI -33.26, 22.93, 0.71, $p=0.71$ ). 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.