Immunosuppressive Treatment for Lupus in the Next Decade

Consideration of the case posed at the beginning of this article illustrates these points. Thus, the patient clearly had moderately severe proliferative LN. A reasonable option would be to use three pulses of IV-MP followed by either AZA, MMF, or IV-CY, although most people would perhaps choose MMF as initial treatment because of the better data supporting the use of MMF versus AZA in this setting, and the potential for ovarian toxicity of IV-CY. Should the patient fail to achieve complete remission after three to six months of AZA or MMF, then she could be switched to a combination of IV-MP with IV-CY with protection of her ovaries.

In actual practice, the patient we described remitted initially with MMF but developed a severe nephritic flare with increase of her creatinine while on MMF. She was rescued with IV-MP and IV-CY pulses and reached remission after seven monthly pulses. While on maintenance quarterly IV-CY pulses, she had another flare of her nephritis and was switched to rituximab and MMF. She achieved remission after the second cycle of rituximab. She has subsequently been in remission for more than five years on 1 g/day of MMF and low-dose, alternate-day prednisone. Meanwhile, she was married and was switched to AZA because of her desire to have a family.

As this case shows well, current treatment of lupus nephritis poses many challenges and demands flexibility and willingness to try various approaches using data from well-conducted studies as a guide. While much needs to be done, for the future, we are optimistic that additional trials of biologics will be successful. Until that time, immunosuppressive drugs are here to stay. Optimization of the existing therapies by incorporating them in the best possible strategy is clearly the way to go.

Drs. Boumpas and Bertsias both work in Internal Medicine and Rheumatology, Clinical Immunology and Allergy, at the University of Crete Medical School in Greece.

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