Early DORIS Remission As Gold Standard in Clinical Practice
INTRODUCTION
Hydroxychloroquine, GCs, and non-steroidal anti-inflammatory drugs are considered first-line therapies for the treatment of SLE...
While these treatments can be effective, often they do not lead to complete remission.
...with immunosuppressants commonly introduced when a patient fails to respond adequately.1,2
Through a proactive treat-to-target approach with early and sustained DORIS remission as the primary goal...1,2,4-6
Less than 10% of people with SLE are currently achieving remission.3
...there is an opportunity to help more people with SLE to live longer, with less harm.7
Prioritising DORIS remission is critical
*For patients receiving 0-5mg/day GCs, attainment of DORIS was associated with a 48-87% reduction in risk of mortality from a prospective longitudinal APLC cohort study (N=3811).9
Driving early DORIS remission as Gold standard in clinical practice
Reduces the risk of mortality, as organ damage is a key driver in early mortality.8,9
Prevents irreversible organ damage accrual by controlling disease activity early and reduces risk of flares.10
Reduces long-term GCs exposure, minimising GC-related toxicity.11,12
Improves quality of life by avoiding flare-driven treatment escalation.8,9,11-13
DORIS remission is widely recognised as the key indicator of disease control in SLE,27 and prioritising early and sustained DORIS remission as the treatment goal is supported by global treatment recommendations from the European Alliance of Associations for Rheumatology (EULAR) and the American College of Rheumatology (ACR) as well as other local treatment recommendations.1,2,28
The ACR and EULAR guidelines recommend:1,2
The early introduction of immunosuppressant and/or biologic therapies, when appropriate.
Effectively tapering GCS in clinical practice
Guidelines recommend GCs only as a bridging therapy.1,2
For the patients who have been exposed for longer, the DELPHI Experts consensus* provides guidance in clinical practice for physicians implementing an GC-tapering approach:29
Week-by-week
detail
Mild SLE disease: 4-week regimen resulting in withdrawal of GCs, if disease was controlled.29
Moderate SLE disease:
>15-week regimen to taper from GCs, with optional use of IV MP at a dose of 0.125–0.500 g/day for up to 3 days.29
Severe non-renal SLE:
Long-term dependency on low-dose GC treatment:
either a 12-week regimen or 6-month regimen.29
IV MP at a dose of 0.25–0.50 g/day for up to 3 days, followed by GC-tapering to <2.5 mg/day by Week 25.29
*AstraZeneca provided funding for this study. The authors retained full control of the content and made the final decisions for all aspects of this abstract.
Summary
The treatment paradigm in SLE has shifted, with DORIS remission now recommended as the goal of therapy.
Patients should no longer have to endure multiple cycles of treatments that do not sufficiently manage their disease and can lead to irreversible long-term damage.
Faster diagnosis and earlier intervention may prevent harm and help patients experience a better quality of life for longer.
Through shared decision-making and close collaboration among patients, healthcare professionals, and policymakers, these guidelines need to be widely adopted and effectively translated into routine clinical practice to make remission a reality for more patients.
References & Abbreviations
Z4-82067 - June 2026
Treat-to-Target (T2T) strategy for SLE
Initial assessment
T2T strategy implementation
Considering: Risks/benefits of the treatment plan and treatment response
After appropriate interval and depending on the target
Considering:
• Patient's clinical stats • Patient's needs
Regular medication adjustments
Optimisation of the therapeutic strategy
Monitoring target achievement
Establishment of an individualised target
Take steps to achieve the target
Adapted from Parra Sánchez A, et al.5
DORIS remission attainment has been shown to reduce the risk of mortality.9
LLDAS‡ for ≥50% of observed time
DORIS remission§ on ≤5 mg/day prednisolone for ≥50% of observed time
DORIS remission§ on <5 mg/day prednisolone for ≥50% of observed time
0.51 (0.31, 0.85)
P=0.01
P=0.03
P=0.01
0.52 (0.29, 0.93)
0.31 (0.12, 0.77)
Adjusted HR|| (95% CI)
GC-free DORIS remission§ for ≥50% of observed time
P=0.05
1.5
1
0.5
0
Prospective longitudinal APLC cohort study (N=3811)*
Multivariable model for risk of mortality among patients with SLE in DORIS remission or LLDAS†
Adapted from Kandane-Rathnayake R, et al.9
*Data collected between 1 May 2013–31 December 2020 across 13 countries. Median follow-up: 2.8 years (IQR: 1.0–5.3).
Multivariable model including 3204 patients, of whom 70 patients had complete data for all follow-up visits.
‡LLDAS was defined as SLEDAI-2K ≤4, excluding major organ activity, absence of new SLEDAI-2K activity compared with the preceding visit, PGA ≤1 (0–3), and daily prednisolone dose ≤7.5 mg/day; antimalarial and immunosuppressant use was permitted.
§Remission was defined according to the DORIS definition of remission: clinical SLEDAI score=0, PGA score <0.5, use of prednisolone (≤5.0 mg/day), and use of antimalarials and standard maintenance doses of immunosuppressants.
**HRs adjusted for current smoking status, gross domestic product, and SDI score.
Being in DORIS remission is associated with reduced risk of accruing organ damage and flares.13
Multinational longitudinal prospective APLC cohort study in patients with high disease activity (N=1029)
Adapted from Kandane-Rathnayake R et al.13
Data from patients in 13 countries participating in the APLC, collected prospectively between 2013–2020 (median study duration of 2.7 years). High disease activity was defined as a SLEDAI-2K score of ≥10 on at least one occasion, with the first visit recording this score set as baseline. Remission was defined according to the DORIS definition of remission: a clinical SLEDAI score of 0, PGA <0.5, a GC dose ≤5 mg/day, with antimalarials and immunosuppressants allowed.
What is the impact of GCs?
An estimated 50% of people with SLE have irreversible organ damage within 5 years of diagnosis due to long-term GCs use and disease activity.14
How can we improve this?
Even a small reduction in daily GC use; 1 mg/day can lower the risk of organ damage.15,16
Burden of SLE
9 out of 10 people with SLE are women.17
Highest risk of developing SLE is young adulthood (aged 15–44 years).17
Because SLE primarily affects women during reproductive and working years,17 the impact goes far beyond physical symptoms
Physical manifestations:
impacts many organs and causes a range of symptoms, including pain, rashes, fatigue, joint swelling, and fevers.1,2,18,19
Broader life burden on women:
impact on reproductive health,17,20 job consistency,21 cost of treatment,22,23 financial strain,24,25 emotional and mental health issues,24,25 stress, and family pressure.26
SLE burden
Finances
Job
Mental health
Treatment
Fertility
Emotions
Family
Stress
What is DORIS remission?
A medical framework defined by:
Zero disease activity (SLEDAI=0 and PGA <0.5) irrespective
of serology.11
Zero or very low-dose GCs (≤5 mg/day).11
Patient may be on antimalarials, immunosuppressives, and biologics.11
For patients not responding to hydroxychloroquine.
While encouraging minimisation of GC use to minimise long-term exposure and potential future organ damage.1,2
Table 1: Summary of recommended GC-tapering regimens.
94 experts from 30 countries completed two online DELPHI rounds, comprising 79 rheumatologists, 11 nephrologists, 3 dermatologists, and 1 internist. Consensus for either agreement or disagreement was achieved in 31/33 statements in Round 2.29
Sammaritano LR et al. Arthritis Care Res (Hoboken). 2025; DOI:10.1002/acr.25690. [Epub ahead of print].
Fanouriakis A et al. Ann Rheum Dis. 2024;83(1):15-29.
Morand E et al. Abstract 2263. ACR Convergence Annual Meeting, 10-15 November 2023.
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Golder V et al. Rheumatology (Oxford). 2020;59(Suppl 5):v19-28.
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Ugarte-Gil MF et al. Lupus Sci Med. 2021;8(1):e000542.
Kandane Rathnayke R et al. Lancet Rheumatol. 2022;4(12):e822-30.
Golder V et al. Lancet Rheumatol. 2019;1(2):e103-10.
Vollenhoven R et al. Lupus Sci Med. 2021;8(1):e000538.
Ruiz-Arruza I et al. Rheumatology (Oxford). 2014;53(8):1470-6.
Kandane-Rathnayake R et al. Rheumatology (Oxford). 2025;64(5):2741-8.
Bruce IN et al. EMJ Rheumatol. 2024;11[Suppl 2]:2-8.
Katsumata Y et al. Ann Rheum Dis. 2024;83:998-1005.
Al Sawah S et al. Lupus Sci Med. 2015;2(1):e000066.
Centers for Disease Control and Prevention (CDC). Available at: https://www.cdc.gov/lupus/data-research/index.html. Last accessed: 30 May 2026.
Kaul A et al. Systemic lupus erythematosus. Nat Rev Dis Primers. 2016;2:16039.
Bruce N et al. Ann Rheum Dis. 2015;74(9):1706-13.
Alnaimat F et al. Int J Womens Health. 2025;17:1849-62.
Booth S et al. Lupus. 2018;27(14):2284-91.
Choi J et al. Abstract EE74. ISPOR annual meeting, 17-20 November 2024.
Meacock R et al. Pharmacoeconomics. 2013;31(1):49-61.
Liu X et al. Rheumatology (Oxford). 2024;63(12):3234-42.
Primavera D et al. Healthcare (Basel). 2024;12(2):233.
Olesińska M, Saletra A. Reumatologia. 2018;56(1):45-54.
Parra Sánchez A et al. Rheumatol Ther. 2023;10(4):1459-77.
Zhao J et al. Rheumatol Immunol Res. 2025;6(3):120-48.
Vital EM et al. Ann Rheum Dis. 2025;84(Suppl 1):1284‑85.
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ACR: American College of Rheumatology; APLC: Asia Pacific Lupus Collaboration; CS: corticosteroids; DORIS: definitions of remission in systemic lupus erythematosus; EULAR: European Alliance of Associations for Rheumatology; GCs: glucocorticoids; HR: hazard ratio; IQR: interquartile range; IV: intravenous; LLDAS: lupus low disease activity state; MP: methylprednisolone; PGA: Physician Global Assessment; SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index; SLE: systemic lupus erythematosus; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; T2T: treat-to-target.
References & Abbreviations
0.13 (0.02, 0.96)
*data collected between 1 May 2013 and 31 December 2020 across 13 countries
*Respondents could choose multiple schemes that they considered acceptable.
†CS-tapering regimen is the reduced-dose regimen from the KDIGO 2024 guidelines for lupus nephritis.
‡Respondents voted that the regimen for active lupus nephritis could also be used in severe non-renal SLE.