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Clinical Decision Making: Evaluating Biologics in Lupus Management - Episode 10

Lupus Treatment Considerations Post Immunosuppressants

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Anne E. Winkler, MD, PhD, MACP shares her approach to treatment in patients with lupus post treatment with immunosuppressants with a focus on treatment sequencing.

Anne E. Winkler, MD, PhD, MACP: When I’m thinking about treating patients with lupus nephritis in a very similar approach that you have as well, I think about those patients who have already developed, who are already on immunosuppressants like mycophenolate or fairly good doses of steroids who then develop lupus nephritis. Those are ones that I’m pulling the newer agents, either the CNIs or belimumab. What a lot of us struggle with is which one to go with. Do you go with voclosporin? Do you go with belimumab? And I look at voclosporin that it’s very quick in onset, you know quickly is it going to help or not, but it’s also associated with the possibility of GFR decreasing, usually because of the arterial or vasal constriction, which may be reversible or may not. Whereas belimumab may take longer but is certainly safer in terms of the renal function. Your thoughts in terms of those kind of 2 agents?

Kristi V. Mizelle, MD, MPH, FACR: I’m being torn there with the choice of those 2 medications, with voclosporin you’re right. If patients already have a lower GFR, then we’re worried about using voclosporin, that would be a reason I would potentially not use voclosporin in that patient population. However, the sort of flip side to that is voclosporin can be very helpful with patients who have a lot of proteinuria. That would be another reason for me to think about. If someone has GFR that is mildly impacted but not terrible. If I have someone with class 4 and/or class 5 who has a GFR that’s 20 or 30, then I’d be hesitant to use voclosporin. Also, voclosporin is great to use when there’s the rest of the lupus is doing well or the SLE is doing well or kind of well, but the lupus nephritis is the main thing that is kind of acting out. However, if there are other manifestations of lupus present, then for me that also makes me lean towards the belimumab as a drug. If there’s skin or joints that are acting up in addition to lupus nephritis flaring, or hematologic abnormalities in addition to lupus nephritis, then I would lean more towards belimumab. That would be where I would lean in essence. Now the comfort level is also different between the nephrologist and the rheumatologist because nephrologists are usually uncomfortable with belimumab because they haven’t used it. They’ve never been the prescribers, and it’s been mostly limited to the rheumatology field. Their comfort level when I’ve had those conversations about choice of treatment, they’re leaning more towards the voclosporin or CNI instead because that’s a comfort level. One of the pluses about the voclosporin is that it doesn’t require monitoring like many of the other CNIs may have in the pass. That’s definitely a plus too if you have adherence issues with your patient. Now with the belimumab part, if you want someone to have observed therapy, that’s another good way to go. Unfortunately, particularly when you have young people, young women, who have disease, sometimes they may not be as vigilant about being- taking their medication regularly, going through some of that rebellious stage that we see sometimes when transitioning with a chronic disease from pediatric to adolescent to adult rheumatology. If you’re concerned about that, belimumab is another way to make sure that patient gets their medication. There are a number of different things we have to parse out in making the decision on which drug to use. But you’re right Anne. We’re going through all these little things in our brains as we’re figuring out “OK. What’s the most important thing that would make me say I need the belimumab versus the voclosporin?” But what I will say is that I’m excited we have them as tools now because we didn’t before, and we would just end up with patients on chronic steroids, which what we talked about earlier, it’s not the best. And I’ll use a Michelle Petri aphorism, which is “P is for poison when it comes to prednisone”. And I say that regularly when I talk about lupus because people love it. Well, patients love it because it makes them feel better quickly. That’s often the answer. “Can’t I just stay on the prednisone?” But unfortunately, it is not good in the long term, we must help steer our patients in that way. But I’m excited about having those 2 new agents to help us in this very difficult medical issue with the lupus nephritis.

Transcript Edited for Clarity