What is the first line of therapy for patients with severe lupus nephritis?
- a) Induction therapy:
Class III/IV lupus nephritis
- • Intravenous (IV) pulse methylprednisolone (500 mg to 1 g) daily for 3 days followed by prednisone 1 mg/kg/day (crescents on biopsy) or 0.5 mg/kg/day (no crescents). Taper after a few weeks to lowest effective dose; plus
- • Mycophenolate mofetil (MMF) 2–3 g/day for 6 months (limited data suggests that African-American and Hispanic patients may respond to MMF better than cyclophosphamide [CYC]), or CYC: high dose IV (500–1000 mg/m 2 monthly × 6 doses) or low dose (Euro-lupus: 500 mg IV every 2 weeks × 6 doses)
- • Note: For patients who fail to improve on MMF, consider switching to CYC. Patients who fail to respond to CYC consider switching to MMF. Patients who fail to respond to both are candidates for rituximab, calcineurin inhibitors (cyclosporine, tacrolimus), or a combination of calcineurin inhibitors and low-dose MMF.
Class V lupus nephritis
- • Oral prednisone 0.5 mg/kg/day for 6 months; plus
- • MMF 2–3 g/day for 6 months
- • Calcineurin inhibitors (cyclosporine/ tacrolimus) can be added to MMF: use caution in patients with renal insufficiency or hypertension. Voclosporin is currently under investigation.
- • IV CYC if other therapies fail
- b) Adjunctive therapies:
- • Hydroxychloroquine (associated with less organ damage in patients with SLE)
- • Angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) if proteinuria ≥0.5 g/24 hours
- • Control blood pressure (BP): should be ≤130/80
- • Statin therapy if low-density lipoprotein (LDL) cholesterol >100 mg/dL
- • Stop smoking
- • Counsel against pregnancy while nephritis is active or creatinine >2mg/dL
- • Rituximab has also been studied in SLE nephritis with controversial results.