Dr. Hahn highlighted several key points in the new guidelines:
- All patients with clinical evidence of active LN should have a renal biopsy unless it is strongly contraindicated.
- Background therapies should be used in all patients with LN: hydroxychloroquine (HCQ); angiotensin inhibitors or angiotensin receptor blockers for patients with proteinuria greater than or equal to 0.5 g per 24 hours; and statin therapy for patients with LDL cholesterol higher than 100 mg/dL.
- Women contemplating pregnancy should receive counseling from their physicians about risk.
- Specific recommendations are given for dosing MMF in patients of different races.
- African Americans and Latinos are not as likely to respond to cyclophosphamide (CYC) as well as other races do, so MMF may be the first choice for therapy.
- Two different regimens of intravenous (IV) CYC therapy are recommended: low-dose “Euro-Lupus” CYC (500 mg IV once every two weeks for a total of six doses), followed by maintenance therapy with daily oral azathioprine or daily oral MMF; and high-dose CYC (500–1,000 mg/m2 IV once a month for six doses), followed by maintenance treatment with MMF or azathioprine. If CYC is being considered for treatment, the “Euro-Lupus” dose is recommended for white patients with Western European or Southern European racial/ethnic backgrounds.
- Recommendations are given for starting doses for glucocorticoids and the situations where pulse therapy is recommended.
- Guidance is provided for switching therapies in patients who do not respond to induction therapy, including the use of rituximab in some cases.
- Either azathioprine or MMF can be used as maintenance therapy for patients who have responded to initiation therapy.
The recommended therapies for patients with LN with cellular crescents or membranous LN may be surprising to some physicians, Dr. Hahn says. For patients with cellular crescents, the new guidelines recommend either CYC or MMF for induction therapy, along with IV pulses of high-dose glucocorticoids and initiation of oral glucocorticoids at the higher range dose. Patients with membranous LN can be started on prednisone plus MMF.
These guidelines are “more mycophenolate heavy than some of the textbooks, and less cyclophosphamide centric than earlier recommendations,” says Dr. Hahn, noting that neither drug has been approved by the Food and Drug Administration for treatment of LN. However, she believes the guidelines may go a long way in persuading reluctant payers to cover these drugs for patients with LN.
Also, the guidelines are “careful to say that nothing is contraindicated, because a physician providing direct care is in the best position to decide what therapies should be initiated, modified, or discontinued,” Dr. Hahn says.
Treatment of RA
The 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis recommends that targeting low disease activity or remission should be the goal of treatment for every patient with established RA or early RA, according to Dr. Singh.4
