Tapering strategies for immunosuppressive, corticosteroid, and biologic therapy in lupus nephritis: a national survey of rheumatology and nephrology practices in Saudi Arabia.

The optimal duration of immunosuppressive (IS) therapy in lupus nephritis (LN) remains unclear, and tapering strategies for IS, corticosteroids (CS), and biologic therapies vary in practice. This study aimed to compare these practices between nephrologists and rheumatologists in Saudi Arabia and to examine factors influencing tapering decisions. We conducted a national cross-sectional 28-item online survey among nephrologists and rheumatologists involved in LN management across Saudi Arabia. A total of 142 physicians participated, evenly divided between the two specialties. Both groups reported that sustained clinical remission, stable renal function, and absence of recent flares were key criteria for tapering. Rheumatologists used the SLEDAI-2 K more frequently than nephrologists for readiness assessment (35.2% vs. 5.6%, p < 0.001) and post-taper monitoring (47.9% vs. 11.3%), whereas nephrologists more often considered repeat kidney biopsy before tapering (25.4% vs. 8.5%, p = 0.006). Rheumatologists predominantly tapered CS first (97.2% vs. 64.8%, p < 0.001). Most physicians initiated IS dose reduction within one year after sustained remission. In adjusted analyses accounting for practice context, nephrologists were less likely to taper CS first (adjusted OR 0.10) or rely on the SLEDAI-2 K (adjusted OR 0.09), but were more likely to delay IS withdrawal, favoring prolonged maintenance before discontinuation (adjusted OR 6.47), and to opt for immediate biologic discontinuation (adjusted OR 7.54). Disease flare was the most commonly reported challenge, with nearly half of physicians re-initiating the same induction therapy. Tapering practices for IS, CS, and biologic therapies in LN differ substantially between specialties, highlighting the need for harmonized, multidisciplinary tapering strategies.