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Clinical Decision Making: Evaluating Biologics in Lupus Management - Episode 9

Treatment Considerations in Lupus Nephritis

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Drs Anne E. Winkler and Kristi V. Mizelle explore relevant treatment options for a patient with lupus nephritis and highlight efficacy and safety considerations.

Kristi V. Mizelle, MD, MPH, FACR: When we see that, my first thought is OK, we’ve got lupus nephritis. What do we need to do now? In my mind, always, I want confirmation of diagnosis. And I’m going to get on the phone with my nephrology colleague and ask them to see her quickly and to do a kidney biopsy. That’s very important. When I’ve talked with some of my nephrology colleagues, because for most patients with lupus, nowadays when there’s lupus nephritis and it’s a very suggestive clinical finding, and you’re improved in creatinine ratio, they will want to start patients on mycophenolate mofetil, that’s not a wrong thing as far as choice of drug per se. However, it’s super important to make sure that we understand what the actual diagnosis is. There can be other things going on that could cause kidney, in manifestations, a nephrotic range proteinuria. We must make sure that we clarify diagnosis. Also, we will never get that opportunity to go back and get this ever again, we won’t have this data 3 years down the road when patients is not doing well, progressing towards end stage renal disease, and we never got a biopsy. There can be coexisting conditions. And we have to make sure that we understand what the appropriate diagnosis is, then that will lead to a choice of appropriate drug. Now as far as lupus nephritis is concerned, the old standard was cytoxan, IV cytoxan. However, studies have been more- have shown often that CellCept or mycophenolate mofetil can be equivalent to and potentially even better than cytoxan and have a better adverse effect profile. Oftentimes, that’s one of the first things you reach for as far as treatment. Our patient had a kidney biopsy, the nephrologist was nice to me and didn’t give me a hard time about doing the biopsy. And it comes back as class 4 mixed with class 5, and there’s some chronicity there. And we'll say it’s a mild to moderate chronicity. That says this has been going on for a little bit. And to me, when we see chronicity, there’s an urgency for treatment. CellCept because there’s already been some damage. Of course, we talked about mycophenolate mofetil, but of course, that takes some time to kick in. And our good old friend corticosteroids come to the rescue for immediate, hopefully to kind of settle down the lupus nephritis immediately, and I would probably start the patient depending on how sick they were, on Prednisone 1 mg per kg per day. And that's standard for most folks who are rheumatologists to do that, and then of course start with steroid-screening medicine fairly quickly with fairly quick escalation to get to appropriate max dose as tolerated without significant adverse effect. And the of course, tamper down that steroid while watching the urine protein creatinine ratio and see how the patient does. Prior to recent drugs that have become available for lupus nephritis, that’s about what we would do. However, in the last 2 years or so, we’ve had several new agents come to the market that can be add-on therapies for lupus nephritis, including belimumab and voclosporin. And those would be options that could be considered initially, just like with many of our other add-on therapies, would be helpful for getting folks off steroids. However, there is some data that suggests starting patients on these things sooner rather than later could help get disease under better control and is superior to just standard of therapy or standard of care. Those are other options that can be used or added on based on your preference and other potential things that might impact your choice of drug, including other medical conditions, etc. We have additional new medications that can be very helpful with the management of lupus nephritis now, and I would have a low threshold to reach for those, especially if patients are not getting to the goals, your outcome, as quickly as you would like. Say the nephrotic is not decreasing the way you want it to. Low threshold to add on additional therapy like belimumab or voclosporin.

Transcript Edited for Clarity