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Clinical Decision Making: Evaluating Biologics in Lupus Management - Episode 5

Treatment Goals for Patients with Lupus

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Kristi V. Mizelle, MD, MPH, FACR shares her treatment goals and discusses the patient characteristics she factors when deciding on a choice of treatment for her patients.

Anne E. Winkler, MD, PhD, MACP: When we do have a lupus patient sitting in our exam room, what are your goals for therapy? And what factors do you usually consider when you're setting up your goals for your patient?

Kristi V. Mizelle, MD, MPH, FACR: Some of that is thinking through what are the manifestations of disease. And that helps you in thinking through what are the most appropriate drugs because certain drugs are better for certain manifestations of lupus. And we may talk about that down the road, but also other things like age, reproductive status, patient preference, the standard of care, of course, which I mentioned earlier, severity of disease, also coexisting medical conditions that might make you lean towards one treatment as opposed to another. There are adherence concerns. Observing therapy may be better for certain patients who you’re concerned about adherence as compared to treatment at home. Also, thinking about prevention of irreversible damage, and preventing adverse effects from the medications that you would want to use. There’s a number of things that’s going through that rheumatology brain while we’re sitting in front of that patient thinking about what’s the best treatment for this patient.

Anne E. Winkler, MD, PhD, MACP: We know that there has been a significant improvement in how we can treat our lupus patients, particularly with now the 2 biologics we have available, as well as we have 2 agents now FDA approved for treatment of lupus nephritis, which have made a big difference because it used to be I could never get patients off steroids very easily. And certainly, one of the reasons I often will use biologics is because I don’t want my patients o steroids but again, if we look at the cohort data in lupus patients, they’re twice as likely to have irreversible organ damage if they’re on chronic steroids versus not. When we think about biologics, are you typically using them in combination with the standard? Are you using it sometimes just by themselves alone, in conjunction with hydroxychloroquine, what is your approach?

Kristi V. Mizelle, MD, MPH, FACR: With all of the biologic studies' patients were on standard of care in addition to the biologic, that’s what the clinical trials guidance when we look at how the studies were created tells us, that’s where we know how things or patients should respond. And it’s uncharted territory which rheumatologist are not totally uncomfortable in but it’s uncharted territory to have patients on biologics without another, oftentimes another immunosuppressant or certainly at least an antimalarial. Most rheumatologists I believe, at this time, are using certainly a biologic with antimalarial medication at the very least, if they are needing, feel like a biologic is necessary for the patient, but many rheumatologists are using biologics after patients have been escalated to immunosuppressants, your methotrexates, your mycophenolate mofetil, your leflunomide, et cetera. And that’s often the combo is an antimalarial and immunosuppressant and a biologic. And then the hope is, is to get rid of steroids, which are often in the place there as well and then begin to pull back as disease is well controlled, maintaining control, but decreasing the number of medications needed to maintain that control. And it’s this whole process of building up getting to remission or low disease activity as much as we can, then dropping off the drugs that are most likely to cause problems long term, which of course, is steroids, and then other drugs as we’re able to. That’s how most rheumatologist are now practicing and using biologics.

Anne E. Winkler, MD, PhD, MACP: I certainly would say, I agree with that. That’s exactly what I do in my practice. And I would say my biggest goal is always to get them off steroids. And then doing well, hopefully, then I may start cutting back on even some of the immunosuppressants.

Transcript Edited for Clarity