Depends on cases; in non-active cases (good responders), from few to several years.

Dear Pr Davatchi, dear friend ,

what do you mean by several years? Is there any  study in this issue? 

It is impossible to do any study on this subject, because we don't know in advance, which patient will become a responder. Even if we could know, we cannot predict which patient will go in remission (the kidney disease) in a few months, in a few years, or in several years. Therefore, how to select patients to form a homogenous group?

It is why it is impossible to have equal groups and test which behavior will give better result. 

Do you think that a comparative study should be done in this topic. After full remission of 4 years with no active disease based for example in SLEDAI, COMPARE PATIENTS WHO CONTINUE IS AND ANOTHER GROUPE WITHOUT IS

Conventional practice is to withdraw immunosuppression after a minimum of 3 years in sustained remission. So you could try and withdraw in select patients who have no clinical activity and follow them up closely.

It would always be interesting to do such studies. However, as the patients were not similar (beginning of the study, treatment received to achieve the remission, time to achieve the kidney disease remission, the maintenance regimen, the duration of  the step down protocol to arrive to the low dose permitting to stop the medication), critics may always be found.  

Nevertheless, it's a very interesting study to do.... We can certainly find a way to perform it. ...no? 

We are also having a good number of patients of Lupus nephritis, being in the corner of India (very small city with a variety of patients with very minimal facility), many of a time we go with clinical finding, protinuria, ESR to look for disease remission. My personal observation is most of the patients require maintenance corticosteroid for prolonged period. Same issues with Takayasu artritis, a disease which is very common here.

Thank youDr Bhupen for your comment. I also thing that mainting less than 5mg of prednisone for prolonged period is wise. 

40 years ago we used to give “courses” for rheumatoid arthritis (RA), stop after remission and treat again when (inevitable) recurrence occurs.

Then we learned that RA patients had better be treated with maintenance dose of the drug to which they responded without time limit. 

For lupus nephritis, well designed studies to address this issue are difficult to conduct.

I see no rationale in stopping the treatment after improvement.  I would give the patient a minimal dose of a drug that is likely to be well tolerated with periodic observation. Anyway periodic observation in lupus is mandatory with or without nephritis. I try to avoid maintenance steroids.

I have a patient who had Juvenile lupus nephritis 25 years ago and responded nicely to immuno-suppressor therapy. She is still in remission. I only stopped the treatment when she decided to marry and have a baby. I kept her on chloroquine since it is safe for the fetus. Whether chloroquine worked for her as a maintenance drug or not is open to speculation. But she is under close monitoring.

In cancer therapy the trend now is to give metronomic dose  treatment (oral and continuous low dose) instead of high dose “pulse” therapy. Studies are on the way. Perhaps we could design such studies for rheumatic diseases.

immunosuppression should be continued for 3 years after remission. yet in patients with high ds-DNA levels, relapses are possible. hence it would be wise to continue HCQ and low dose CS 5mg/day for few months and if the urine remains normal, then Cs to 2.5 mg/day and then withdraw completely keeping the patient in  observation for any relapse. about HCQ, i would never withdraw completely

In such cases immunsupressant should be tapered and discontinued gradually. But never stop HCQ unless patient has a side effect.

3 years with strict control

I agree with tapering immunosuppressants and maintaining HCQ. And watch for a flare. 

My practice is to continue for 3-5 years. I'd cut short for severe side effects, but continue in those without. I'd continue hydroxychloroquine  in most patients.

Plaquenil should never be ceased. MMF at 3 years though for certain groups such proven frequent relapsers in multiple ways then perhaps continued suppression is needed. In patients who have presented with profound hypocomplementemia and subsequent infection I think they need continued MMF, plus plaq plus low dose (5mg) pred

After remission, I would maintain immunosuppressant full dose for 6-12 months if there is no side effect, together with Plaguenil and low dose prednisone( 5mg/d), then taper gradually. Prednisone will be stopped after 2.5 mg/d for 6 months without flare, but never stop Plaguenil.  immunosuppressant may be stopped  if there is no relapse after 5 years.

Give a look at these three relevants papers,

Professor Maurizio Salvadori from Italy

Thank you very much Professor Salvadori.