The Impact of Early Belimumab Use on Successful Glucocorticoid Tapering to a Low Maintenance Dose in Treatment-naïve, Newly Diagnosed Systemic Lupus Erythematosus.

OBJECTIVES

Glucocorticoids rapidly control inflammation in systemic lupus erythematosus (SLE), yet prolonged use contributes to organ damage and increased mortality. Optimal tapering strategies in newly diagnosed, treatment-naïve patients remain unclear. This study aimed to identify predictors for glucocorticoid tapering, focusing on early belimumab initiation and the safety of high-dose induction therapy.

METHODS

We retrospectively studied newly diagnosed, treatment-naïve SLE patients initiated on prednisolone (PSL) > 20 mg/day between April 2006 and April 2024. Early belimumab exposure was defined as initiation of therapy within 26 weeks of diagnosis with continuation for at least 26 weeks. Kaplan-Meier analysis determined the time to achieve PSL ≤ 7.5 mg/day and ≤ 5 mg/day. Cox proportional hazards models identified factors associated with early tapering.

RESULTS

Of 537 patients, 106 met the inclusion criteria. The median initial PSL dose was 50.0 mg/day (IQR: 30.0-75.0), tapering to 5.00 mg/day (IQR: 3.00-7.62) by week 52. Early belimumab exposure was significantly associated with tapering to ≤ 7.5 mg/day (HR 4.05, 95% CI: 1.95-8.38, p < 0.001) and showed a trend toward achieving ≤ 5 mg/day. Patients with early belimumab exposure also had significantly higher LLDAS attainment (HR 4.07, CI 1.97-8.43, p < 0.001). High-dose induction (PSL > 40 mg/day) and rapid tapering were not associated with delayed tapering or increased cumulative exposure.

CONCLUSION

Early belimumab initiation was associated with glucocorticoid tapering and higher LLDAS attainment in treatment-naïve SLE patients, potentially reducing long-term steroid-related risks. High-dose glucocorticoid induction therapy and rapid tapering approaches appear safe without increasing cumulative glucocorticoid exposure, supporting their consideration in clinical practice.