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Clinical Decision Making: Evaluating Biologics in Lupus Management - Episode 8

Lupus Case Scenario: Treatment Approach

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An expert in lupus management provides insight into her treatment approach for a 24-year-old African American female diagnosed with lupus nephritis.

Kristi V. Mizelle, MD, MPH, FACR: We see the patient, she has an ANA 1 to 640, homogeneous pattern. She’s got the high double stranded DNA, low C3, and she does have synovitis on exam of her small joints of her hands and feet. And has what looks like a malar rash as well. We say, OK, looks like we are arriving at potential what could be called a Lupus. OK, let’s make sure we’ve ruled out other stuff that could potentially be present at the same time, or could sort of interfere. We make sure we are checking our rheumatoid blood studies, potentially checking X rays. We make sure we’re comfortable with our diagnosis. Then, OK, we’ve got a diagnosis of lupus, we’re very comfortable. With her manifestations, if she’s got mild synovitis on exam, I would then suggest an antimalarial, that would be completely appropriate, as well as UV light protection with sunscreen regularly with a high SPF. I usually recommend at least 50 to 70 for patients who have lupus as a way to try to prevent UV light triggering lupus flares or progression or increased disease activity. And then I’d send her on her way and see how she does with the antimalarial medication.

Anne E. Winkler, MD, PhD, MACP: If she wasn’t doing as well, now has lipid nephritis. How would you approach that knowing that she’s on antimalarials and leflunomide?

Kristi V. Mizelle, MD, MPH, FACR: Right. Coming in with some fatigue, some swelling in the legs, a mildly increased blood pressure, which is different for her, right? If she’s been doing well for a year and a half, 2 years, and then comes in with these things that then says, we’ve got to think about, is there something else going on? And that just gives us an opportunity to kind of go back and say, every time we’re seeing patients, we must be evaluating for any signs or symptoms, or laboratory findings, that would hint at Lupus activity. We check for signs, symptoms, laboratory findings, that would be an indication that there’s increasing lupus activity, even if the patient feels well. We have to continue to have, as I say, our antenna up. And you said earlier in the discussion, checking our urine protein to creatinine ratios to make sure that patients are doing OK, and that does not increase in proteinuria, also check in the UA to make sure there’s not microscopic hematuria. We’re doing those things, and she comes back and now she’s got a urine protein to creatinine ratio of 4, that’s not good. That’s nephrotic range proteinuria and we’re concerned that she has bad lupus nephritis, we’re looking at nephrotic range proteinuria, we’re looking at class 5, potentially with also some overlap, potentially with other classes of lupus nephritis. But typically, we’d be concerned about class 4 for the most part, that’s the big bad lupus nephritis that would get very worried, people will lose their kidney function. Our big bad lupus nephritis that we get worried about because it can definitely progress quickly and can progress towards loss of renal function very quickly and lead patients to have to be dialysis dependent.

Transcript edited for clarity