The European League Against Rheumatism has released its first guidelines for the management of lupus nephritis. These differ in important ways from guidelines on the lupus nephritis issued earlier this year by the American College of Rheumatology (ACR).
The EULAR guidelines on adult and pediatric lupus nephritis are available in free full text online, published in the November issue of the Annals of the Rheumatic Diseases.
• advise renal biopsy at the first sign of kidney involvement, even when urinary findings are normal;
• recommend mycophenolic acid as the initial choice for immunosuppressive therapy, although low-dose IV cyclophosphamide in combination with steroids is also recommended;
• recommend azathioprine as induction treatment, with close followup, for certain patients who have no adverse clinical or histological risk factors, while ACR advises it only as maintenance therapy;
• favor switching patients to an alternative agent if they fail to improve in 3-4 months or show at least a partial response after 6-12 months. ACR guidelines would wait 6 months before switching drugs for patients who fail to respond; and
• offer specific dosing advice on steroids.
Lupus nephritis management is of great importance because it is the major cause of death for patients with lupus, observed rheumatology Bevra Hahn MD of the UCLA Medical Center last May, in a podcast about the ACR guidelines. She pointed out that the mycophenolate group are not yet approved by the FDA for lupus nephritis, but said the guidelines developers had hoped their inclusion might encourage approval.