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Paredes-Ruiz D, Martin-Iglesias D, Ruiz-Irastorza G. Balancing risks and benefits in the use of hydroxychloroquine and glucocorticoids in systemic lupus erythematosus. Expert Rev Clin Immunol 2024; 20:359-373. [PMID: 38112074 DOI: 10.1080/1744666x.2023.2294938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Hydroxychloroquine (HCQ) and glucocorticoids (GCs) constitute the oldest and more used drugs in the treatment of systemic lupus erythematosus (SLE). Despite this long experience, both are still subject to a number of uncertainties, mainly regarding the dose. AREAS COVERED We review the main mechanisms of action, the clinical and toxic effects of HCQ and GCs and analyze the recommendations for the use of both in guidelines published since 2018. We offer a set of recommendations based on the pharmacology, mechanisms of action and clinical evidence. EXPERT OPINION HCQ is the backbone therapy for SLE, and a judicious use must be accomplished, using doses that allow a good control of lupus without compromising the safety of treatments very much prolonged over the time. Stable doses of 200 mg/day seem to accomplish both conditions. GCs should be used more judiciously, with methyl-prednisolone pulses as the main therapy for inducing rapid remission and doses ≤5-2.5 mg/day be never exceeded in long-term maintenance treatments.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Daniel Martin-Iglesias
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, The Basque Country, Spain
- Department of Medicine, University of the Basque Country, The Basque Country, Spain
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Menn-Josephy H, Hodge LS, Birardi V, Leher H. Efficacy of Voclosporin in Proliferative Lupus Nephritis with High Levels of Proteinuria. Clin J Am Soc Nephrol 2024; 19:309-318. [PMID: 38110196 PMCID: PMC10937024 DOI: 10.2215/cjn.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND In a phase 3 study of adults with active lupus nephritis, addition of voclosporin to mycophenolate mofetil (MMF) and low-dose glucocorticoids led to significant improvements in the proportion of participants achieving complete and partial renal response as well as sustained reduction in proteinuria. This analysis examined the efficacy and safety of voclosporin in a subgroup of the phase 3 study with proliferative lupus nephritis and high levels of proteinuria. METHODS Participants were randomized to oral voclosporin (23.7 mg twice daily) or placebo for 12 months; all participants received MMF and low-dose glucocorticoids. This analysis includes participants with class III or IV (±class V) lupus nephritis and baseline urine protein-creatinine ratio (UPCR) ≥3 g/g. Efficacy end points included complete renal response (UPCR ≤0.5 g/g with stable eGFR, low-dose glucocorticoids, and no rescue medication), partial renal response (≥50% reduction from baseline UPCR), and UPCR over time. Safety outcomes were also assessed. RESULTS A total of 148 participants were in the voclosporin ( n =76) and control ( n =72) arms. At 12 months, 34% and 11% of participants in the voclosporin and control arms, respectively, achieved a complete renal response (odds ratio, 4.43; 95% confidence interval [CI], 1.78 to >9.99; P = 0.001). A partial renal response was achieved by 65% of the voclosporin arm and 51% of the control arm at 12 months (odds ratio, 1.60; 95% CI, 0.8 to 3.20; P = 0.18). More voclosporin- than control-treated participants achieved UPCR ≤0.5 g/g (51% versus 26%), and voclosporin-treated participants met this end point significantly earlier (hazard ratio, 2.07; 95% CI, 1.19 to 3.60; P = 0.01). The incidence of adverse events was similar between the arms; mean eGFR values remained stable and within normal range in both arms. CONCLUSIONS Addition of voclosporin to MMF and low-dose glucocorticoids resulted in a significantly higher proportion of participants with proliferative lupus nephritis achieving complete and partial renal responses as well as earlier reductions in proteinuria, with no evidence of worsening kidney function.
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Affiliation(s)
| | - Lucy S. Hodge
- Aurinia Pharmaceuticals Inc., Edmonton, Alberta, Canada
| | | | - Henry Leher
- Aurinia Pharmaceuticals Inc., Edmonton, Alberta, Canada
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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Parodis I, Depascale R, Doria A, Anders HJ. When should targeted therapies be used in the treatment of lupus nephritis: Early in the disease course or in refractory patients? Autoimmun Rev 2024; 23:103418. [PMID: 37625673 DOI: 10.1016/j.autrev.2023.103418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
Although the prognosis of lupus nephritis (LN) has improved over the last few decades, 5-20% of patients still progress to kidney failure. Hence, there is an unmet need to improve the management of LN. Two novel drugs, belimumab and voclosporin, have been recently approved for LN and obinutuzumab is in the late stage of development. In randomised controlled trials (RCTs), all these drugs, added to the standard-of-care, were more effective than standard-of-care alone in achieving renal response. Now the question is: should these new drugs be used early in the disease course or just in refractory patients? The main reasons supporting the early use are based on the RCTs that demonstrated benefits when combinatory regimen was initiated early in incident and relapsing patients leading to a higher proportion of patients to achieve renal response, hence reducing nephron loss and the risk of kidney failure. The main reasons supporting the use of the combinatory regimens primarily in relapsing/refractory patients acknowledge that many patients responded well even without add-on medications, allowing a more economic use of innovative and costly drugs. However, good predictors of renal response to standard-of-care are lacking and, thus, the decision of adding new treatments early or just in refractory or relapsing patients has to consider drug access, risks of over or undertreatment, and preservation of kidney function in high-risk individuals.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology, Dermatology, and Rheumatology, Karolinska University Hospital, Stockholm, Sweden; Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Roberto Depascale
- Deparment of Medicine DIMED, Division of Rheumatology, University of Padua, Padua, Italy
| | - Andrea Doria
- Deparment of Medicine DIMED, Division of Rheumatology, University of Padua, Padua, Italy.
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig-Maximilians-University, Munich, Germany
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Mejia-Vilet JM, Turner-Stokes T, Houssiau F, Rovin BH. Kidney involvement in systemic lupus erythematosus: From the patient assessment to a tailored treatment. Best Pract Res Clin Rheumatol 2023:101925. [PMID: 38151362 DOI: 10.1016/j.berh.2023.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
In the last few years, several studies have provided new evidence for the diagnosis, management, and follow-up of patients with lupus nephritis. Evidence showing dissociation between clinical and histological findings has prompted reevaluation of the role of the kidney biopsy as a tool for diagnosis and follow-up. In therapeutics, four immunosuppressive schemes now have supporting evidence for use as initial therapy. Current challenges include individualized selection of the best immunosuppressive regimen, an unmet need for non-invasive biomarkers of disease activity to inform treatment responses and guide subsequent therapy, holistic patient management in this complex, multisystem disease, and ultimately the development of more targeted therapies directed at specific effector pathways driving glomerular inflammation and damage in order to improve treatment response. In this communication, we review the diagnostic and therapeutic approach to lupus nephritis, as well as evaluation of response to therapy and disease control.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Tabitha Turner-Stokes
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Frederic Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Service de Rhumatologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University, Columbus, OH, United States.
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Moysidou GS, Mastrogiorgakis D, Boumpas D, Bertsias G. Management of systemic lupus erythematosus: A new scenario. Best Pract Res Clin Rheumatol 2023:101895. [PMID: 37978040 DOI: 10.1016/j.berh.2023.101895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
The introduction of targeted biological agents in systemic lupus erythematosus (SLE) has created a momentum for improving overall disease management and patients' prognosis. To achieve this, a comprehensive strategy is required spanning the entire patient journey from diagnosis to prevention and management of late complications and comorbidities. In this review, we focus on four aspects that are closely linked to SLE prognosis, namely early disease recognition and treatment initiation, reduction of the cumulative glucocorticoid exposure, attainment of well-defined targets of remission and low disease activity, prevention of flares and, kidney-protective strategies with non-immune-directed agents. We review the recent literature related to these topics in conjunction with the existing treatment recommendations, highlighting areas of uncertainty and providing guidance towards facilitating the care of SLE patients.
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Affiliation(s)
- Georgia-Savina Moysidou
- Rheumatology-Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Mastrogiorgakis
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Iraklio and University of Crete Medical School, Iraklio, Greece
| | - Dimitrios Boumpas
- Rheumatology-Clinical Immunology Unit, 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece; Laboratory of Autoimmunity and Inflammation, Centre of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Iraklio and University of Crete Medical School, Iraklio, Greece; Laboratory of Rheumatology, Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Foundation for Research & Technology - Hellas (FORTH), Iraklio, Greece.
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Paredes-Ruiz D, Ruiz-Irastorza G, Amoura Z. Systemic lupus erythematosus and glucocorticoids: A never-ending story? Best Pract Res Clin Rheumatol 2023:101873. [PMID: 37957076 DOI: 10.1016/j.berh.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 11/15/2023]
Abstract
Glucocorticoids (GCs) continue to be essential agents for the management of systemic lupus erythematosus, since there are no other drugs able to active remission of active disease so rapidly. However, their potential for causing irreversible damage greatly limit their use. Fortunately, some strategies may help take advantage of their huge anti-inflammatory power while limiting GC-induced side effects. This article reviews the pharmacological basis of GC action and their translation into the clinical ground. We also offer the practical approach for the use of GC in induction and maintenance therapy as well as the strategies for GC withdrawal of the respective practice of the authors. The three main basic principles are a) using methyl-prednisolone pulses to induce remission not only in severe disease; b) limiting initial doses of prednisone to ≤30 mg/d, with rapid tapering to ≤5 mg/d, which should be the dose for maintenance therapy; and c) individualizing the decision and the strategy to withdraw GCs. Long-term therapy with HCQ and the early introduction of immunosuppressive treatment would help achieve these objectives.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bizkaia, Spain.
| | - Zahir Amoura
- Sorbonne Université, Faculté de Médecine, Groupement Hospitalier Pitié Salpêtrière, Centre National de Référence du Lupus Systémique, du Syndrome des Antiphospholipides et autres maladies auto-immunes, Service de Médecine Interne 2, Institut E3M, CIMI-Paris, Paris, France
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Avasare R, Drexler Y, Caster DJ, Mitrofanova A, Jefferson JA. Management of Lupus Nephritis: New Treatments and Updated Guidelines. KIDNEY360 2023; 4:1503-1511. [PMID: 37528520 PMCID: PMC10617804 DOI: 10.34067/kid.0000000000000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023]
Abstract
Management of lupus nephritis has evolved considerably over the past years. Here, we provide a comprehensive review of clinical trials that form the basis for the Kidney Disease: Improving Global Outcomes and EULAR/ERA-EDTA updated guidelines and present day trials that will change the landscape of lupus nephritis therapy in years to come. In addition, we highlight the issues related to cost of therapy, resistant disease, and downstream adverse effects of specific therapies.
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Affiliation(s)
- Rupali Avasare
- Nephrology and Hypertension, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Yelena Drexler
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Dawn J. Caster
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Alla Mitrofanova
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Alchi MB, Lever R, Flossmann O, Jayne D. Efficacy and safety of low- versus high-dose glucocorticoid regimens for induction of remission of anti-neutrophil cytoplasm antibody-associated vasculitis: a systematic review and meta-analysis. Scand J Rheumatol 2023; 52:564-573. [PMID: 37339385 DOI: 10.1080/03009742.2023.2211387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/04/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) remain a cornerstone of the initial management of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV), but have several dose-dependent side effects, in particular infections. The optimal dosing and tapering of oral GCs for remission induction are unknown. A systematic review and meta-analysis was undertaken to determine the efficacy and safety of low- versus high-dose GC regimens. METHOD A systematic search of MEDLINE, Embase, and PubMed databases was conducted. Clinical studies using a GC-based induction protocol were selected. A daily dose of 0.5 mg/kg or < 30 mg/day oral prednisolone equivalent by the start of week 4 of the induction tapering schedule marked the threshold between high- and low-dose GCs. Risk ratios (RRs) were calculated by the random effects model for outcomes of remission and infection. Relapse events were summarized using risk differences with 95% confidence intervals (CIs). RESULTS In total, 1145 participants were included in three randomized controlled trials and two observational studies, of whom 543 were assigned to the low-dose GC group and 602 to the high-dose GC group. A low-dose GC regimen was non-inferior to high-dose GCs with respect to outcomes of remission (RR 0.98, 95% CI 0.95-1.02, p = 0.37; I2 = 0%) and relapse (risk difference 0.03, 95% CI -0.01 to 0.06, p = 0.15; I2 = 12%), while significantly reducing the incidence of infection (RR 0.60, 95% CI 0.39-0.91, p = 0.02; I2 = 65%). CONCLUSION Studies with low-dose GC regimens in AAV are associated with fewer infections while obtaining equivalent efficacy.
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Affiliation(s)
- M B Alchi
- School of Pharmacy, University College London, London, UK
| | - R Lever
- School of Pharmacy, University College London, London, UK
| | - O Flossmann
- Berkshire Kidney Unit, Royal Berkshire Hospital, Reading, UK
| | - D Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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10
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Bulanov NM, Bobkova IN, Moiseev SV. [State-of-the-art paradigm of corticosteroid therapy for immune-mediated inflammatory kidney diseases]. TERAPEVT ARKH 2023; 95:451-456. [PMID: 38158962 DOI: 10.26442/00403660.2023.06.202265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
Since 1950's corticosteroids (CS) have remained the cornerstone of immunosuppressive therapy for immune-mediated kidney diseases. However multiple adverse events, associated with the prolonged CS therapy, became the basis for the development of novel treatment approaches. Current evidence supports the implementation of the steroid-sparing regimens for the treatment of different types of glomerulonephritis. Randomised controlled trial PEXIVAS demonstrated the efficacy and safety of early steroid tapering, starting from the second week of therapy, in patients with ANCA-associated vasculitis with kidney involvement. Several trials showed the efficacy of oral prednisolone 0.3-0.5 mg/kg/daily as a part of multitarget therapy for severe proliferative lupus nephritis. A combination of calcineurin inhibitors and low-dose CS are effective for remission induction in membranous nephropathy, as well as the steroid-free rituximab regimen for the patients with moderate risk of disease progression. Medium dose CS showed promising effect in patients with IgA-nephropathy. Long-term high dose CS remain the standard-of-care for the treatment of minimal change disease and focal segmental glomerulosclerosis, however patients with steroid-dependent and relapsing disease tacrolimus and rituximab can help to achieve steroid-sparing effect. The role of CS pulse-therapy is currently debated, nevertheless it remains a compulsory treatment in several conditions. Thus, overall trend is directed towards the minimization of the maximal doses of CS and/or treatment duration. However, to implement this approach morphological verification of the diagnosis and personalized assessment of the potential risk and benefit are required.
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Affiliation(s)
- N M Bulanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I N Bobkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S V Moiseev
- Sechenov First Moscow State Medical University (Sechenov University)
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Bhat R, Tonutti A, Timilsina S, Selmi C, Gershwin ME. Perspectives on Mycophenolate Mofetil in the Management of Autoimmunity. Clin Rev Allergy Immunol 2023:10.1007/s12016-023-08963-3. [PMID: 37338709 DOI: 10.1007/s12016-023-08963-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
Before becoming a cornerstone in the treatment of numerous immune-mediated diseases, mycophenolate mofetil (MMF) was first introduced as an immunosuppressive agent in transplant immunology and later received the attention of rheumatologists and clinicians involved in the management of autoimmune diseases. MMF is now a widespread immunosuppressive drug for the treatment of several conditions, including lupus nephritis, interstitial lung disease associated with systemic sclerosis, and anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis while being efficacious also as rescue therapy in various orphan diseases, including dermatomyositis and IgA-associated nephropathy. Similarly, case reports or series support a possible use of MMF in other rare autoimmune diseases. Beyond modulating lymphocyte activation, MMF acts on other immune and non-immune cells and these effects may explain the therapeutic profile of this medication. The effects of MMF are broadly characterized by the impact on the immune system and the antiproliferative and antifibrotic changes induced. In this latter case, mechanistic data on fibroblasts may in the future allow to reevaluate the use of MMF in selected patients with inflammatory arthritis or systemic sclerosis. Attention must be paid towards the possible occurrence of adverse events, such as gastrointestinal complaints and teratogenicity, while the risk of infections and cancer related to MMF needs to be further investigated.
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Affiliation(s)
- Rithika Bhat
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Suraj Timilsina
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, USA.
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Zen M, Salmaso L, Barbiellini Amidei C, Fedeli U, Bellio S, Iaccarino L, Doria A, Saia M. Mortality and causes of death in systemic lupus erythematosus over the last decade: Data from a large population-based study. Eur J Intern Med 2023; 112:45-51. [PMID: 36774306 DOI: 10.1016/j.ejim.2023.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To assess mortality rates (MRs), standardized mortality ratios, and causes of death in systemic lupus erythematosus (SLE) in a population-based study. METHODS We analyzed linked administrative health databases of the Veneto Region (Italy, 4,900,000 residents). SLE was defined by any hospital diagnosis or healthcare copayment exemption for SLE. We analyzed mortality from January 1st, 2012, until December 31st, 2021. MRs per 1000 were stratified by year, sex, and age group. Standardized mortality ratios were derived by comparing MRs of the general regional population. Causes of death were coded using the ICD-10 coding system and they were grouped in: SLE, infectious diseases, cardiovascular diseases (CVD), cancer, or others. RESULTS Among 4283 SLE prevalent cases, 603 deaths occurred, corresponding to an average annual standardized MR of 18.6 per 1000 person/year (95% CI 17.0-20.2). Out of 1092 incident SLE patients, 90 died with a peak in the first year after diagnosis (MR 26.5 per 10,000 person/month). Standardized mortality ratio was 2.65 (95% CI 2.13-3.26) overall, and highest among younger patients (<45 years: 5.59, 95% CI 2.05-12.4). Five- and 8-year survival were 91% and 89%, respectively. About half of the deaths had CVD or cancer as underlying cause, whereas infections were less frequently reported. CONCLUSIONS Although the medium-term survival since diagnosis is good, SLE mortality is still higher than that of the general population, especially in youngest patients. Nowadays, CVD seems to be the major cause of deaths in SLE, whereas infections account for a low proportion of deaths, at least in Western countries.
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Affiliation(s)
- Margherita Zen
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy
| | - Laura Salmaso
- Clinical Governance Unit, Azienda Zero, Veneto Region, Italy
| | | | - Ugo Fedeli
- Epidemiological Department, Azienda Zero, Veneto Region, Italy
| | - Stefania Bellio
- Clinical Governance Unit, Azienda Zero, Veneto Region, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Italy.
| | - Mario Saia
- Clinical Governance Unit, Azienda Zero, Veneto Region, Italy
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Enríquez-Merayo E, Cuadrado MJ. Steroids in Lupus: Enemies or Allies. J Clin Med 2023; 12:jcm12113639. [PMID: 37297834 DOI: 10.3390/jcm12113639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
Glucocorticoids are the gold standard treatment for reducing immune activation and inflammation in a wide range of inflammatory and systemic autoimmune diseases. Glucocorticoids have potent and fast actions that quickly relieve some symptoms and lower mortality in some life-threatening conditions, but they also have side effects that limit the duration of treatment and the dose used. Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by the involvement of numerous organs and systems and the production of autoantibodies. Most current treatments include the use of corticosteroids and immunosuppressive medications. Glucocorticoids in SLE have been classically used not only to induce remission or treat an acute situation but also as maintenance therapy. During the last decades, new approaches to managing SLE have emerged, but corticosteroids continue to be part of all therapeutic regimes. There is more and more evidence about the side effects related to the use (or abuse) of steroids and their relationship with the accrual damage. In this manuscript, we try to make a critical review of the published literature about the benefit and side effects/damage that can be attributed to the use of glucocorticoids.
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Affiliation(s)
- Eugenia Enríquez-Merayo
- Universitary Hospital 12 de Octubre, 28041 Madrid, Spain
- School of Medicine, Universitary Clínica de Navarra, 28027 Madrid, Spain
| | - Maria J Cuadrado
- School of Medicine, Universitary Clínica de Navarra, 28027 Madrid, Spain
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Zen M, Gatto M, Depascale R, Regola F, Fredi M, Andreoli L, Franceschini F, Urban ML, Emmi G, Ceccarelli F, Conti F, Bortoluzzi A, Govoni M, Tani C, Mosca M, Ubiali T, Gerosa M, Bozzolo EP, Canti V, Cardinaletti P, Gabrielli A, Tanti G, Gremese E, De Marchi G, De Vita S, Fasano S, Ciccia F, Pazzola G, Salvarani C, Negrini S, Di Matteo A, De Angelis R, Orsolini G, Rossini M, Faggioli P, Laria A, Piga M, Cauli A, Scarpato S, Rossi FW, De Paulis A, Brunetta E, Ceribelli A, Selmi C, Prete M, Racanelli V, Vacca A, Bartoloni E, Gerli R, Zanatta E, Larosa M, Saccon F, Doria A, Iaccarino L. Early and Late Response and Glucocorticoid-Sparing Effect of Belimumab in Patients with Systemic Lupus Erythematosus with Joint and Skin Manifestations: Results from the Belimumab in Real Life Setting Study-Joint and Skin (BeRLiSS-JS). J Pers Med 2023; 13:jpm13040691. [PMID: 37109077 PMCID: PMC10146447 DOI: 10.3390/jpm13040691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
AIM To assess the efficacy of belimumab in joint and skin manifestations in a nationwide cohort of patients with SLE. METHODS All patients with skin and joint involvement enrolled in the BeRLiSS cohort were considered. Belimumab (intravenous, 10 mg/kg) effectiveness in joint and skin manifestations was assessed by DAS28 and CLASI, respectively. Attainment and predictors of DAS28 remission (<2.6) and LDA (≥2.6, ≤3.2), CLASI = 0, 1, and improvement in DAS28 and CLASI indices ≥20%, ≥50%, and ≥70% were evaluated at 6, 12, 24, and 36 months. RESULTS DAS28 < 2.6 was achieved by 46%, 57%, and 71% of patients at 6, 12, and 24 months, respectively. CLASI = 0 was achieved by 36%, 48%, and 62% of patients at 6, 12, and 24 months, respectively. Belimumab showed a glucocorticoid-sparing effect, being glucocorticoid-free at 8.5%, 15.4%, 25.6%, and 31.6% of patients at 6, 12, 24, and 36 months, respectively. Patients achieving DAS-LDA and CLASI-50 at 6 months had a higher probability of remission at 12 months compared with those who did not (p = 0.034 and p = 0.028, respectively). CONCLUSIONS Belimumab led to clinical improvement in a significant proportion of patients with joint or skin involvement in a real-life setting and was associated with a glucocorticoid-sparing effect. A significant proportion of patients with a partial response at 6 months achieved remission later on during follow-up.
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Affiliation(s)
- Margherita Zen
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Francesca Regola
- ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, 25123 Brescia, Italy
| | - Micaela Fredi
- ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, 25123 Brescia, Italy
| | - Laura Andreoli
- ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, 25123 Brescia, Italy
| | - Franco Franceschini
- ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, 25123 Brescia, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Firenze, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Firenze, Italy
| | - Fulvia Ceccarelli
- Dipartimento Universitario di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari (SCIAC) 'Sapienza' University, 00185 Rome, Italy
| | - Fabrizio Conti
- Dipartimento Universitario di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari (SCIAC) 'Sapienza' University, 00185 Rome, Italy
| | - Alessandra Bortoluzzi
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna-Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Marcello Govoni
- Rheumatology Unit, Azienda Ospedaliero-Universitaria S. Anna-Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Chiara Tani
- Rheumatology, University of Pisa, 56124 Pisa, Italy
| | - Marta Mosca
- Rheumatology, University of Pisa, 56124 Pisa, Italy
| | - Tania Ubiali
- Clinical Rheumatology Unit Milano, ASST Gaetano Pini, Department of Clinical Sciences and Community Health, Lombardia, 20129 Milan, Italy
| | - Maria Gerosa
- Clinical Rheumatology Unit Milano, ASST Gaetano Pini, Department of Clinical Sciences and Community Health, Lombardia, 20129 Milan, Italy
| | - Enrica P Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20100 Milan, Italy
| | - Valentina Canti
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20100 Milan, Italy
| | - Paolo Cardinaletti
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Armando Gabrielli
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Giacomo Tanti
- Division of Rheumatology, Università Cattolica del Sacro Cuore Sede di Roma, 00168 Rome, Italy
| | - Elisa Gremese
- Division of Rheumatology, Università Cattolica del Sacro Cuore Sede di Roma, 00168 Rome, Italy
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Ginevra De Marchi
- Rheumatology Unit, University of Udine, Medical Area, 33100 Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, University of Udine, Medical Area, 33100 Udine, Italy
| | - Serena Fasano
- Deparment of Precision Medicine Napoli, Università degli Studi della Campania Luigi Vanvitelli, 81100 Caserta, Italy
| | - Francesco Ciccia
- Deparment of Precision Medicine Napoli, Università degli Studi della Campania Luigi Vanvitelli, 81100 Caserta, Italy
| | - Giulia Pazzola
- Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Rheumatology Unit, University of Modena and Reggio Emilia, 41125 Reggio Emilia, Italy
| | - Simone Negrini
- Internal Medicine Unit, Department of Internal Medicine, Università degli Studi di Genova, 16146 Genoa, Italy
| | - Andrea Di Matteo
- Deparment of Clinical and Experimental Sciences, Università Politecnica delle Marche, Rheumatology Clinic, 60131 Ancona, Italy
| | - Rossella De Angelis
- Deparment of Clinical and Experimental Sciences, Università Politecnica delle Marche, Rheumatology Clinic, 60131 Ancona, Italy
| | | | - Maurizio Rossini
- Unit of Rheumatology, University of di Verona, 37134 Verona, Italy
| | - Paola Faggioli
- ASST OVEST Milanese Presidio di Legnano, 20025 Legnano, Italy
| | - Antonella Laria
- ASST OVEST Milanese Presidio di Magenta, 20013 Magenta, Italy
| | - Matteo Piga
- Rheumatology Unit, AOU University Clinic, University of Cagliari, 09124 Cagliari, Italy
| | - Alberto Cauli
- Rheumatology Unit, AOU University Clinic, University of Cagliari, 09124 Cagliari, Italy
| | | | - Francesca Wanda Rossi
- Dipartimento di Scienze Mediche, Traslazionali e Centro di Ricerca Immunologia Base e Clinica (CISI), University of Napoli Federico II, 80131 Napoli, Italy
| | - Amato De Paulis
- Dipartimento di Scienze Mediche, Traslazionali e Centro di Ricerca Immunologia Base e Clinica (CISI), University of Napoli Federico II, 80131 Napoli, Italy
| | - Enrico Brunetta
- IRCCS Humanitas Research Hospital, Milan, Italy, 20089 Milan, Italy
| | - Angela Ceribelli
- Department of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20133 Milan, Italy
| | - Carlo Selmi
- Department of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20133 Milan, Italy
| | - Marcella Prete
- Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, University of Bari, 70125 Bari, Italy
| | - Vito Racanelli
- Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, University of Bari, 70125 Bari, Italy
| | - Angelo Vacca
- Unit of Internal Medicine, Department of Biomedical Sciences and Human Oncology, University of Bari, 70125 Bari, Italy
| | - Elena Bartoloni
- Rheumatology Unit, Department of Medicine, University of Perugia, 06121 Perugia, Italy
| | - Roberto Gerli
- Rheumatology Unit, Department of Medicine, University of Perugia, 06121 Perugia, Italy
| | - Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Maddalena Larosa
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Francesca Saccon
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
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Rojas-Rivera JE, García-Carro C, Ávila AI, Espino M, Espinosa M, Fernández-Juárez G, Fulladosa X, Goicoechea M, Macía M, Morales E, Porras LFQ, Praga M. Consensus document of the Spanish Group for the Study of the Glomerular Diseases (GLOSEN) for the diagnosis and treatment of lupus nephritis. Nefrologia 2023; 43:6-47. [PMID: 37211521 DOI: 10.1016/j.nefroe.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 05/23/2023] Open
Abstract
A significant number of patients with systemic lupus erythematosus (between 20% and 60% according to different reported series) develop lupus nephritis in the course of its evolution, which directly influences their quality of life and vital prognosis. In recent years, the greater knowledge about the pathogenesis of systemic lupus and lupus nephritis has allowed relevant advances in the diagnostic approach and treatment of these patients, achieving the development of drugs specifically aimed at blocking key pathogenic pathways of the disease. Encouragingly, these immunomodulatory agents have shown in well-powered, randomized clinical trials good clinical efficacy in the medium-term, defined as proteinuria remission and preservation of kidney function, with an acceptable safety profile and good patient tolerability. All this has made it possible to reduce the use of corticosteroids and other potentially more toxic therapies, as well as to increase the use of combined therapies. The present consensus document carried out by the Glomerular Diseases Working Group of the Spanish Society of Nephrology (GLOSEN), collects in a practical and summarized, but rigorous way, the best currently available evidence about the diagnosis, treatment, and follow-up of lupus nephritis patients, including cases of special situations, with the main objective of providing updated information and well-founded clinical recommendations to treating physicians, to improve the diagnostic and therapeutic approach to our patients.
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Affiliation(s)
- Jorge E Rojas-Rivera
- Hospital Universitario Fundación Jiménez Díaz, Servicio de Nefrología e Hipertensión, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Servicio de Nefrología, Madrid, Spain.
| | - Clara García-Carro
- Hospital Universitario Clínico San Carlos, Servicio de Nefrología. Madrid, Spain.
| | - Ana I Ávila
- Hospital Dr. Peset, Servicio de Nefrología, Valencia, Spain
| | - Mar Espino
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain
| | - Mario Espinosa
- Hospital Universitario Reina Sofía, Servicio de Nefrología, Cordoba, Spain
| | | | - Xavier Fulladosa
- Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Servicio de Nefrología, Barcelona, Spain
| | - Marian Goicoechea
- Hospital Universitario Gregorio Marañón, Servicio de Nefrología, Madrid, Spain
| | - Manuel Macía
- Hospital Universitario Nuestra Señora de la Candelaria, Servicio de Nefrología, Tenerife, Spain
| | - Enrique Morales
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
| | - Luis F Quintana Porras
- Hospital Clínic de Barcelona, Servicio de Nefrología, Barcelona, Spain; Departamento de Medicina, Universidad de Barcelona, IDIBAPS, Servicio de Nefrología, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
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El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, Sarhan E, El Gaafary M, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Tabra SAA, Eissa M, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian evidence-based consensus on clinical practice recommendations for the management of lupus nephritis. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00146-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Lupus nephritis (LN) affects a substantial number of the patients living with Systemic lupus erythematosus (SLE), representing a major cause of morbidity and mortality. Patients with lupus nephritis should be referred to a lupus nephritis expert who can confirm the diagnosis, assess the level of disease activity, and offer guidance on treatment and monitoring of the disease, as well as its consequences and side effects. The aim of this guideline was to develop recommendations for the management of adult lupus patients, including lupus nephritis diagnosis, assessment, and monitoring.
Nineteen key clinical questions were identified by scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. Literature review team performed a systematic review to summarize evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for LN. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 19 recommendation items, categorized into 11 sections to address the main LN categories, were obtained. The percentage of those who agreed with the recommendations (ranks 7–9) ranged from 90.5 to 100%. The phrasing of all 19 clinical standards identified by the scientific committee was agreed upon (i.e., 75% of respondents strongly agreed or agreed).
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of lupus nephritis and strategies to reach optimal treat to target outcomes in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient situation.
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Documento de consenso del Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) para el diagnóstico y tratamiento de la nefritis lúpica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Jayne D, Walsh M, Merkel PA, Peh CA, Szpirt W, Puéchal X, Fujimoto S, Hawley C, Khalidi N, Jones R, Flossmann O, Wald R, Girard L, Levin A, Gregorini G, Harper L, Clark W, Pagnoux C, Specks U, Smyth L, Ito-Ihara T, de Zoysa J, Brezina B, Mazzetti A, McAlear CA, Reidlinger D, Mehta S, Ives N, Brettell EA, Jarrett H, Wheatley K, Broadhurst E, Casian A, Pusey CD. Plasma exchange and glucocorticoids to delay death or end-stage renal disease in anti-neutrophil cytoplasm antibody-associated vasculitis: PEXIVAS non-inferiority factorial RCT. Health Technol Assess 2022; 26:1-60. [PMID: 36155131 DOI: 10.3310/pnxb5040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasm antibody-associated vasculitis is a multisystem, autoimmune disease that causes organ failure and death. Physical removal of pathogenic autoantibodies by plasma exchange is recommended for severe presentations, along with high-dose glucocorticoids, but glucocorticoid toxicity contributes to morbidity and mortality. The lack of a robust evidence base to guide the use of plasma exchange and glucocorticoid dosing contributes to variation in practice and suboptimal outcomes. OBJECTIVES We aimed to determine the clinical efficacy of plasma exchange in addition to immunosuppressive therapy and glucocorticoids with respect to death and end-stage renal disease in patients with severe anti-neutrophil cytoplasm antibody-associated vasculitis. We also aimed to determine whether or not a reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen with respect to death and end-stage renal disease. DESIGN This was an international, multicentre, open-label, randomised controlled trial. Patients were randomised in a two-by-two factorial design to receive either adjunctive plasma exchange or no plasma exchange, and either a reduced or a standard glucocorticoid dosing regimen. All patients received immunosuppressive induction therapy with cyclophosphamide or rituximab. SETTING Ninety-five hospitals in Europe, North America, Australia/New Zealand and Japan participated. PARTICIPANTS Participants were aged ≥ 16 years with a diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis, and either proteinase 3 anti-neutrophil cytoplasm antibody or myeloperoxidase anti-neutrophil cytoplasm antibody positivity, and a glomerular filtration rate of < 50 ml/minute/1.73 m2 or diffuse alveolar haemorrhage attributable to active anti-neutrophil cytoplasm antibody-associated vasculitis. INTERVENTIONS Participants received seven sessions of plasma exchange within 14 days or no plasma exchange. Oral glucocorticoids commenced with prednisolone 1 mg/kg/day and were reduced over different lengths of time to 5 mg/kg/day, such that cumulative oral glucocorticoid exposure in the first 6 months was 50% lower in patients allocated to the reduced-dose regimen than in those allocated to the standard-dose regimen. All patients received the same glucocorticoid dosing from 6 to 12 months. Subsequent dosing was at the discretion of the treating physician. PRIMARY OUTCOME The primary outcome was a composite of all-cause mortality and end-stage renal disease at a common close-out when the last patient had completed 10 months in the trial. RESULTS The study recruited 704 patients from June 2010 to September 2016. Ninety-nine patients died and 138 developed end-stage renal disease, with the primary end point occurring in 209 out of 704 (29.7%) patients: 100 out of 352 (28%) in the plasma exchange group and 109 out of 352 (31%) in the no plasma exchange group (adjusted hazard ratio 0.86, 95% confidence interval 0.65 to 1.13; p = 0.3). In the per-protocol analysis for the non-inferiority glucocorticoid comparison, the primary end point occurred in 92 out of 330 (28%) patients in the reduced-dose group and 83 out of 325 (26%) patients in the standard-dose group (partial-adjusted risk difference 0.023, 95% confidence interval 0.034 to 0.08; p = 0.5), thus meeting our non-inferiority hypothesis. Serious infections in the first year occurred in 96 out of 353 (27%) patients in the reduced-dose group and in 116 out of 351 (33%) patients in the standard-dose group. The rate of serious infections at 1 year was lower in the reduced-dose group than in the standard-dose group (incidence rate ratio 0.69, 95% confidence interval 0.52 to 0.93; p = 0.016). CONCLUSIONS Plasma exchange did not prolong the time to death and/or end-stage renal disease in patients with anti-neutrophil cytoplasm antibody-associated vasculitis with severe renal or pulmonary involvement. A reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen and was associated with fewer serious infections. FUTURE WORK A meta-analysis examining the effects of plasma exchange on kidney outcomes in anti-neutrophil cytoplasm antibody-associated vasculitis is planned. A health-economic analysis of data collected in this study to examine the impact of both plasma exchange and reduced glucocorticoid dosing is planned to address the utility of plasma exchange for reducing early end-stage renal disease rates. Blood and tissue samples collected in the study will be examined to identify predictors of response to plasma exchange in anti-neutrophil cytoplasm in antibody-associated vasculitis. The benefits associated with reduced glucocorticoid dosing will inform future studies of newer therapies to permit further reduction in glucocorticoid exposure. Data from this study will contribute to updated management recommendations for anti-neutrophil cytoplasm antibody-associated vasculitis. LIMITATIONS This study had an open-label design which may have permitted observer bias; however, the nature of the end points, end-stage renal disease and death, would have minimised this risk. Despite being, to our knowledge, the largest ever trial in anti-neutrophil cytoplasm antibody-associated vasculitis, there was an insufficient sample size to assess clinically useful benefits on the separate components of the primary end-point: end-stage renal disease and death. Use of a fixed-dose plasma exchange regimen determined by consensus rather than data-driven dose ranging meant that some patients may have been underdosed, thus reducing the therapeutic impact. In particular, no biomarkers have been identified to help determine dosing in a particular patient, although this is one of the goals of the biomarker plan of this study. TRIAL REGISTRATION This trial is registered as ISRCTN07757494, EudraCT 2009-013220-24 and Clinicaltrials.gov NCT00987389. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael Walsh
- Department of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Peter A Merkel
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Chen Au Peh
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - Xavier Puéchal
- National Referral Centre for Rare Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Carmel Hawley
- Department of Nephrology, The University of Queensland, Brisbane, QLD, Australia
| | - Nader Khalidi
- Department of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Rachel Jones
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Ron Wald
- Department of Rheumatology, St Michael's Hospital, Toronto, ON, Canada
| | - Louis Girard
- Department of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Adeera Levin
- Department of Nephrology, St Paul's Hospital, Vancouver, BC, Canada
| | - Gina Gregorini
- Department of Nephrology, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Lorraine Harper
- Department of Nephrology, University of Birmingham, Birmingham, UK
| | - William Clark
- Department of Nephrology, University of Western Ontario, London, ON, Canada
| | - Christian Pagnoux
- Department of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ulrich Specks
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lucy Smyth
- Department of Nephrology, The Royal Devon and Exeter Hospital, Exeter, UK
| | - Toshiko Ito-Ihara
- Clinical and Translational Research Centre, Kyoto Prefecture University of Medicine, Kyoto, Japan
| | - Janak de Zoysa
- Department of Nephrology, North Shore Hospital, Auckland, New Zealand
| | - Biljana Brezina
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Mazzetti
- The Research Institute, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Carol A McAlear
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, QLD, Australia
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Hugh Jarrett
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Alina Casian
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Charles D Pusey
- Department of Nephrology, Imperial College London, London, UK
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Recommendations for Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2022; 48:617-636. [DOI: 10.1016/j.rdc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Gelder T, Lerma E, Engelke K, Huizinga RB. Voclosporin: a novel calcineurin inhibitor for the treatment of lupus nephritis. Expert Rev Clin Pharmacol 2022; 15:515-529. [PMID: 35763288 DOI: 10.1080/17512433.2022.2092470] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Lupus nephritis (LN) is a severe manifestation of systemic lupus erythematosus. Standard-of-care immunosuppressive therapies achieve poor complete renal response (CRR) rates, with considerable toxicity. This article reviews voclosporin, a novel oral calcineurin inhibitor (CNI) approved for treatment of adults with active LN by the US Food and Drug Administration (the FDA) in January 2021. AREAS COVERED : This review summarizes the chemical properties, pharmacokinetics, and pharmacodynamics of voclosporin, and its efficacy and safety in LN, based on literature review covering PubMed searches, manufacturers' websites and documents produced by the FDA. EXPERT OPINION : Voclosporin is a CNI with a consistent pharmacokinetic-pharmacodynamic relationship resulting from enhanced calcineurin binding and reduced drug and metabolite load. This profile permits therapeutic efficacy in LN at a dose associated with relatively low calcineurin inhibition, and therefore a potentially improved safety profile. Pivotal trials demonstrated a significant benefit of adding voclosporin to standard therapy, with rapid reduction in proteinuria, and a clinically meaningful and significantly higher CRR rate at 1 year. At approved doses for LN, potential advantages of voclosporin versus historical experience with CNIs include lack of need for therapeutic drug monitoring, benign metabolic, lipid and electrolyte profile, and no impact on mycophenolate mofetil levels.
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Affiliation(s)
- Teun Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago College of Medicine/Advocate Christ Medical Center, Chicago, IL, USA
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Treat-to-target in systemic lupus erythematosus: advancing towards its implementation. Nat Rev Rheumatol 2022; 18:146-157. [PMID: 35039665 DOI: 10.1038/s41584-021-00739-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 02/08/2023]
Abstract
The treat-to-target (T2T) concept has improved outcomes for patients with diabetes, hypertension and rheumatoid arthritis. This therapeutic strategy involves choosing a well-defined, relevant target, taking therapeutic steps, evaluating whether the target has been achieved, and taking action if it has not. The T2T principle has been embraced by systemic lupus erythematosus (SLE) experts, but measurable and achievable outcomes, and therapeutic options, are needed to make this approach possible in practice. Considerable evidence has been generated regarding meaningful 'state' outcomes for SLE. Low disease activity has been defined and studied, and the most aspirational goal, remission, has been defined by the Definition of Remission in SLE task force. By contrast, current therapeutic options in SLE are limited, and more effective and safer therapies are urgently needed. Fortunately, clinical trial activity in SLE has been unprecedented, and encouraging results have been seen for novel therapies, including biologic and small-molecule agents. Thus, with the expected advent of such treatments, it is likely that sufficiently diverse therapies for SLE will be available in the foreseeable future, allowing the routine implementation of T2T approaches in the care of patients with SLE.
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22
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OUP accepted manuscript. J Appl Lab Med 2022; 7:1450-1467. [DOI: 10.1093/jalm/jfac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/25/2022] [Indexed: 11/14/2022]
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23
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Alamilla-Sanchez ME, Alcala-Salgado MA, Alonso-Bello CD, Fonseca-Gonzalez GT. Mechanism of Action and Efficacy of Immunosupressors in Lupus Nephritis. Int J Nephrol Renovasc Dis 2021; 14:441-458. [PMID: 34924767 PMCID: PMC8675090 DOI: 10.2147/ijnrd.s335371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Approximately 70% of the patients with systemic lupus erythematosus will have clinical evidence of kidney damage during their evolution. Patients with impaired renal function at onset and those with recurrent flares have a poor prognosis. Understanding the mechanism of action of immunosuppressants is essential for proper prescription. Steroids inhibit the DNA sequence that promotes the release of inflammatory cytokines. Phosphoramide mustard, metabolite of cyclophosphamide, cross-link with the DNA, causing the aggregation of an alkyl group, causing cell death. Mycophenolate inhibits inosine monophosphate dehydrogenase, prevents de novo synthesis of guanine, inducing cell arrest in S phase. Azathioprine blocks the synthesis of purines and induces apoptosis. Calcineurin inhibitors prevent the dephosphorylation of NFAT and reduce the production of interleukin 2. Antimalarials alter the enzymatic release of lysosomes by increasing intravesicular pH. The mechanism of action of rituximab is related to complement-dependent cytotoxicity and the elimination of anti-CD20-labeled B cells. Progress in the knowledge and management of low doses of steroids may change the current paradigm and reduce the frequency of related adverse events. Mycophenolate seems to be a better choice than cyclophosphamide for induction, it is also preferred over azathioprine as a maintenance immunosuppressive agent, although azathioprine is preferred in women with a desire for conception, those pregnant, or with low resources. For treatment-resistant cases, tacrolimus, rituximab or belimumab may be effective. Ongoing clinical trials with new drugs offer promising results.
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Affiliation(s)
| | | | - Cesar D Alonso-Bello
- Department of Immunology, Centro Medico Nacional "20 de Noviembre", Mexico City, Mexico
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Bandhan IH, Islam MN, Ahmad HI, Ahmedullah AK. Outcome of low-dose prednisolone use for the induction of remission in lupus nephritis patients. Int J Rheum Dis 2021; 25:121-130. [PMID: 34894070 DOI: 10.1111/1756-185x.14265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/27/2021] [Accepted: 12/03/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study aimed to compare the efficacy of low-dose prednisolone with conventional high-dose regimen in proliferative lupus nephritis (LN) for remission. METHODS This open-label randomized clinical trial was conducted in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. A total of 32 LN patients were randomized into low-dose (experimental) and high-dose (control) groups. All subjects received standard dose of intravenous (I/V) methylprednisolone and pulse I/V cyclophosphamide. Oral prednisolone, 0.5 mg/kg/d and 1 mg/kg/d were given to experimental and control groups respectively for initially 4 weeks then tapered. The patients were followed for 24 weeks. The rates of renal remission (complete and partial) were assessed at 24 weeks. The disease activity, biochemical markers, and quality of life were evaluated at baseline and at 24 weeks. RESULTS Complete renal remission was achieved by 66.7% of patients in each group (P = .99). Renal remission (partial/complete) was achieved by 86.7% and 83.3% of patients in the prednisolone low-dose group and high-dose group respectively (P = .99). In between groups, no significant difference was observed in the improvement of active urinary sediments, serum creatinine level, anti-double-stranded DNA level, complements level, disease activity and Short Form-12 score. The prednisolone dose-related adverse events like cushingoid facies, abdominal stria, infections and serious adverse events like death occurred more in the high-dose prednisolone group. CONCLUSIONS It has been observed that low-dose prednisolone regimen may be effective in LN. Steroid dose-related side effects and rate of infections were lower in this group.
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Affiliation(s)
- Iftekhar Hussain Bandhan
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.,Directorate General of Health Services, Dhaka, Bangladesh
| | - Md Nazrul Islam
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Habib Imtiaz Ahmad
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.,Department of Rheumatology, Enam Medical College & Hospital, Savar, Dhaka, Bangladesh
| | - Abul Khair Ahmedullah
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Mejia-Vilet JM, Malvar A, Arazi A, Rovin BH. The lupus nephritis management renaissance. Kidney Int 2021; 101:242-255. [PMID: 34619230 DOI: 10.1016/j.kint.2021.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022]
Abstract
Over the past year, and for the first time ever, the US Food and Drug Administration approved 2 drugs specifically for the treatment of lupus nephritis (LN). As the lupus community works toward understanding how to best use these new therapies, it is also an ideal time to begin to rethink the overall management strategy of LN. In addition to new drugs, this must include how to use kidney biopsies for management and not just diagnosis, how molecular technologies can be applied to interrogate biopsies and how such data can impact management, and how to incorporate LN biomarkers into management paradigms. Herein, we will review new developments in these areas of LN and put them into perspective for disease management now and in the future.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology, Instituto Nacional de Ciencas Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Ana Malvar
- Department of Nephrology, Hospital Fernandez, Buenos Aires, Argentina
| | - Arnon Arazi
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Brad H Rovin
- Department of Medicine and Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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26
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 640] [Impact Index Per Article: 213.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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27
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Rathmann J, Jayne D, Segelmark M, Jönsson G, Mohammad AJ. Incidence and predictors of severe infections in ANCA-associated vasculitis: a population-based cohort study. Rheumatology (Oxford) 2021; 60:2745-2754. [PMID: 33253372 DOI: 10.1093/rheumatology/keaa699] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/19/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the incidence rate, predictors and outcome of severe infections in a population-based cohort of ANCA-associated vasculitis (AAV). METHODS The study included 325 cases of AAV (152 female) diagnosed from 1997 through 2016 from a defined geographic area in Sweden. All severe infection events (requiring hospitalization and treatment with intravenous antimicrobials) were identified. The Birmingham vasculitis activity score (BVAS) was used to evaluate disease activity, and organ damage was assessed using the vasculitis damage index (VDI). Patients were followed from time of AAV diagnosis to death or December 2017. RESULTS A total of 129 (40%) patients suffered at least one severe infection. In 2307 person-years (PY) of follow-up, 210 severe infections were diagnosed. The incidence rate of severe infections was 9.1/100 PY and was highest during the first year following AAV diagnosis at 22.1/100 PY (P < 0.001). Pneumonia, sepsis and urinary tract infection were the most common infections. Opportunistic infections constituted only 6% of all severe infections. In Cox regression analysis age and BVAS at diagnosis were the only factors independently predicting severe infection [hazard ratio: 1.54 (P < 0.001) and 1.27 (P = 0.001), respectively]. Severe infection was associated with poorer prognosis with respect to median VDI score 12 months post-AAV diagnosis, renal survival and mortality. Severe infections were the cause of death in 32 patients (22% of all deaths). CONCLUSION . Severe infection is a common problem in AAV, with the most important prognostic factors being older age and high disease activity at diagnosis. Severe infections are associated with permanent organ damage and high mortality.
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Affiliation(s)
- Jens Rathmann
- Division of Rheumatology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mårten Segelmark
- Division of Nephrology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Göran Jönsson
- Division of Infectious Diseases, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Aladdin J Mohammad
- Division of Rheumatology, Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
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Chandwar K, Pandya S. Is combination of immunosuppressive drugs the answer to reduce glucocorticoid burden in patients with lupus nephritis? Clin Rheumatol 2021; 40:5121-5123. [PMID: 34318360 DOI: 10.1007/s10067-021-05868-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kunal Chandwar
- Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Sapan Pandya
- Department of Clinical Immunology and Rheumatology, Sardar Vallabhbhai Patel Institute of Medical Sciences and Research and Smt. NHL Municipal Medical College, Ahmedabad, 380006, Gujarat, India
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29
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Ruiz-Irastorza G, Dueña-Bartolome L, Dunder S, Varona J, Gomez-Carballo C, Dominguez-Cainzos J, Rodrigo-Manjon A, Bueno L, Richez C, Duffau P, Blanco P, Lazaro E. Eurolupus cyclophosphamide plus repeated pulses of methyl-prednisolone for the induction therapy of class III, IV and V lupus nephritis. Autoimmun Rev 2021; 20:102898. [PMID: 34274543 DOI: 10.1016/j.autrev.2021.102898] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To study whether adding repeated 125 mg methyl-prednisolone pulses (MP) to Eurolupus fortnightly intravenous cyclophosphamide (CYC) improves remission of lupus nephritis (LN) compared with recommended schedules. METHODS Observational comparative study of patients with biopsy-confirmed class III, IV or V LN: 30 in the mycophenolate (MMF) group, 25 in the CYC group and 38 in the CYC-MP group. The main efficacy outcome was complete response at 12 months. RESULTS Patients in the CYC-MP group received lower doses of prednisone within 6 months (mean 8.5 mg/d, vs. 15 mg/d in the MMF group vs. 24 mg/d in the CYC group, respectively). The complete response rates at 12 months were: CYC-MP 86%; CYC 56%; MMF 47% (p = 0.002) at Pr/Cr <0.5; CYC-MP 86%; CYC 65%; MMF 63% (p = 0.07) at Pr/Cr ≤0.7. The cumulative 12-month response rates for the CYC-MP, CYC and MMF groups were, respectively, 0.90, 0.58 and 0.63 (p = 0.004). In the adjusted Cox model, patients receiving CYC-MP were more likely to achieve complete response at Pr/Cr <0.5 than those in the MMF (HR vs. CYC-MP 0.33, 95%CI 0.16-0.65) and the CYC groups (HR vs. CYC-MP 0.47, 95%CI 0.21-1.04). Glucocorticoid-related toxicity was seen in 2.6% of the CYC-MP group, 24% of the CYC group and 20% of the MMF group (p = 0.029). CONCLUSION The addition MP of 125 mg to each fortnightly dose of 500 mg of CYC improves response rates and reduces the need for oral glucocorticoids in patients with class III, IV and V LN.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain; University of the Basque Country, Barakaldo, Spain.
| | - Luis Dueña-Bartolome
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Susanna Dunder
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Jimena Varona
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Carlota Gomez-Carballo
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Jokin Dominguez-Cainzos
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Alejandro Rodrigo-Manjon
- Autoimmune Diseases Research Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Laura Bueno
- Service of Nephrology, Hospital Universitario Cruces, Barakaldo, Spain
| | - Christophe Richez
- UMR CNRS5164, ImmunoconcEpT, Bordeaux University, Bordeaux, France; ACRONIM University Hospital Federation, Bordeaux, France
| | - Pierre Duffau
- UMR CNRS5164, ImmunoconcEpT, Bordeaux University, Bordeaux, France; Internal Medicine Department, Saint-Andre Hospital, Bordeaux, France; Rheumatology Department, Pellegrin Hospital, Bordeaux, France; ACRONIM University Hospital Federation, Bordeaux, France
| | - Patrick Blanco
- UMR CNRS5164, ImmunoconcEpT, Bordeaux University, Bordeaux, France; Immunology Department, Pellegrin Hospital, Bordeaux, France; ACRONIM University Hospital Federation, Bordeaux, France
| | - Estibaliz Lazaro
- UMR CNRS5164, ImmunoconcEpT, Bordeaux University, Bordeaux, France; Internal Medicine Department, Haut-Lévêque Hospital, Bordeaux, France; ACRONIM University Hospital Federation, Bordeaux, France
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30
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Kostopoulou M, Fanouriakis A, Cheema K, Boletis J, Bertsias G, Jayne D, Boumpas DT. Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations. RMD Open 2021; 6:rmdopen-2020-001263. [PMID: 32699043 PMCID: PMC7425195 DOI: 10.1136/rmdopen-2020-001263] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/22/2020] [Indexed: 01/24/2023] Open
Abstract
Objectives To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. Methods According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. Results We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). Conclusions There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
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Affiliation(s)
- Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece .,Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece, and Medical School, University of Cyprus, Nicosia, Cyprus
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Rovin BH, Teng YKO, Ginzler EM, Arriens C, Caster DJ, Romero-Diaz J, Gibson K, Kaplan J, Lisk L, Navarra S, Parikh SV, Randhawa S, Solomons N, Huizinga RB. Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet 2021; 397:2070-2080. [PMID: 33971155 DOI: 10.1016/s0140-6736(21)00578-x] [Citation(s) in RCA: 217] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Voclosporin, a novel calcineurin inhibitor approved for the treatment of adults with lupus nephritis, improved complete renal response rates in patients with lupus nephritis in a phase 2 trial. This study aimed to evaluate the efficacy and safety of voclosporin for the treatment of lupus nephritis. METHODS This multicentre, double-blind, randomised phase 3 trial was done in 142 hospitals and clinics across 27 countries. Patients with a diagnosis of systemic lupus erythematosus with lupus nephritis according to the American College of Rheumatology criteria, and a kidney biopsy within 2 years that showed class III, IV, or V (alone or in combination with class III or IV) were eligible. Patients were randomly assigned (1:1) to oral voclosporin (23·7 mg twice daily) or placebo, on a background of mycophenolate mofetil (1 g twice daily) and rapidly tapered low-dose oral steroids, by use of an interactive web response system. The primary endpoint was complete renal response at 52 weeks defined as a composite of urine protein creatinine ratio of 0·5 mg/mg or less, stable renal function (defined as estimated glomerular filtration rate [eGFR] ≥60 mL/min/1·73 m2 or no confirmed decrease from baseline in eGFR of >20%), no administration of rescue medication, and no more than 10 mg prednisone equivalent per day for 3 or more consecutive days or for 7 or more days during weeks 44 through 52, just before the primary endpoint assessment. Safety was also assessed. Efficacy analysis was by intention-to-treat and safety analysis by randomised patients receiving at least one dose of study treatment. The trial is registered with ClinicalTrials.gov, NCT03021499. FINDINGS Between April 13, 2017, and Oct 10, 2019, 179 patients were assigned to the voclosporin group and 178 to the placebo group. The primary endpoint of complete renal response at week 52 was achieved in significantly more patients in the voclosporin group than in the placebo group (73 [41%] of 179 patients vs 40 [23%] of 178 patients; odds ratio 2·65; 95% CI 1·64-4·27; p<0·0001). The adverse event profile was balanced between the two groups; serious adverse events occurred in 37 (21%) of 178 in the voclosporin group and 38 (21%) of 178 patients in the placebo group. The most frequent serious adverse event involving infection was pneumonia, occurring in 7 (4%) patients in the voclosporin group and in 8 (4%) patients in the placebo group. A total of six patients died during the study or study follow-up period (one [<1%] patient in the voclosporin group and five [3%] patients in the placebo group). None of the events leading to death were considered by the investigators to be related to the study treatments. INTERPRETATION Voclosporin in combination with MMF and low-dose steroids led to a clinically and statistically superior complete renal response rate versus MMF and low-dose steroids alone, with a comparable safety profile. This finding is an important advancement in the treatment of patients with active lupus nephritis. FUNDING Aurinia Pharmaceuticals.
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Affiliation(s)
- Brad H Rovin
- Department of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Y K Onno Teng
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Cristina Arriens
- Department of Arthritis & Clinical Immunology, Rheumatology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Dawn J Caster
- Department of Medicine, Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, KY, USA
| | - Juanita Romero-Diaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Keisha Gibson
- Department of Medicine, UNC Kidney Center, Chapel Hill, NC, United States
| | - Joshua Kaplan
- Department of Medicine, Rutgers University, Newark, NJ, USA
| | - Laura Lisk
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
| | - Sandra Navarra
- University of Santo Tomas, Manila and St Luke's Medical Center, Quezon City, Philippines
| | - Samir V Parikh
- Department of Nephrology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Simrat Randhawa
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
| | - Neil Solomons
- Clinical Development, Aurinia Pharmaceuticals, Victoria, BC, Canada
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Khanna PP, Khanna D, Cutter G, Foster J, Melnick J, Jaafar S, Biggers S, Rahman AKMF, Kuo HC, Feese M, Kivitz A, King C, Shergy W, Kent J, Peloso PM, Danila MI, Saag KG. Reducing Immunogenicity of Pegloticase With Concomitant Use of Mycophenolate Mofetil in Patients With Refractory Gout: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Arthritis Rheumatol 2021; 73:1523-1532. [PMID: 33750034 DOI: 10.1002/art.41731] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/18/2021] [Accepted: 03/09/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pegloticase is used for the treatment of severe gout, but its use is limited by immunogenicity. This study was undertaken to evaluate whether mycophenolate mofetil (MMF) prolongs the efficacy of pegloticase. METHODS Participants were randomized 3:1 to receive 1,000 mg MMF twice daily or placebo for 14 weeks, starting 2 weeks before receiving pegloticase and continuing while receiving intravenous pegloticase 8 mg biweekly for 12 weeks. Participants then received pegloticase alone from week 12 to week 24. The primary end points were the proportion of patients who sustained a serum urate level of ≤6 mg/dl at 12 weeks and the rate of adverse events (AEs). Secondary end points included 24-week durability of serum urate level ≤6 mg/dl. Fisher's exact test and Wilcoxon's 2-sample test were used for analyses, along with Kaplan-Meier estimates and log rank tests. RESULTS A total of 32 participants received ≥1 dose of pegloticase. Participants were predominantly men (88%), with a mean age of 55.2 years, mean gout duration of 13.4 years, and mean baseline serum urate level of 9.2 mg/dl. At 12 weeks, a serum urate level of ≤6 mg/dl was achieved in 19 (86%) of 22 participants in the MMF arm compared to 4 (40%) of 10 in the placebo arm (P = 0.01). At week 24, the serum urate level was ≤6 mg/dl in 68% of MMF-treated patients versus 30% of placebo-treated patients (P = 0.06), and rates of AEs were similar between groups, with more infusion reactions occurring in the placebo arm (30% versus 0%). CONCLUSION Our findings indicate that MMF therapy with pegloticase is well tolerated and shows a clinically meaningful improvement in targeted serum urate level of ≤6 mg/dl at 12 and 24 weeks. This study suggests an innovative approach to pegloticase therapy in gout.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania, USA
| | | | | | - Jeff Kent
- Horizon Therapeutics, Lake Forest, Illinois, USA
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Fischer-Betz R, Schneider M. [Deescalation and glucocorticoid-free treatment in SLE]. Z Rheumatol 2021; 80:332-338. [PMID: 33721043 DOI: 10.1007/s00393-021-00981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
Treatment of systemic lupus erythematosus (SLE) without permanent glucocorticoid therapy is inconceivable for most patients and their physicians. Although we have significantly improved the prognosis of SLE, management remains constrained by a lack of effective, targeted therapies and the lack of evidence-based approaches to the use of existing compounds. For example, for glucocorticoids (GC), which are used continuously in a majority of patients, there are no evidence-based recommendations for initiation, tapering, and cessation in the treatment of SLE. Even today, GC are without alternatives in acute situations, especially organ- or life-threatening ones. However, due to the known long-term adverse effects, the role of GC is viewed increasingly critically. Long-term data from cohorts show that the use of GC actually contributes to morbidity and mortality in SLE. Strategies to reduce the use of GC in SLE are therefore urgently needed and are proposed in this paper.
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Affiliation(s)
- Rebecca Fischer-Betz
- Poliklinik für Rheumatologie und Hiller Forschungszentrum, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Matthias Schneider
- Poliklinik für Rheumatologie und Hiller Forschungszentrum, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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34
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Tselios K, Gladman DD, Al‐Sheikh H, Su J, Urowitz MB. Medium versus high initial prednisone dose for remission induction in lupus nephritis: A propensity score matched analysis. Arthritis Care Res (Hoboken) 2021; 74:1451-1458. [DOI: 10.1002/acr.24592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/05/2021] [Accepted: 03/02/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Konstantinos Tselios
- Centre for Prognosis Studies in Rheumatic Diseases Toronto Lupus Clinic University Health Network Toronto Ontario Canada
| | - Dafna D Gladman
- Centre for Prognosis Studies in Rheumatic Diseases Toronto Lupus Clinic University Health Network Toronto Ontario Canada
| | - Haifa Al‐Sheikh
- Centre for Prognosis Studies in Rheumatic Diseases Toronto Lupus Clinic University Health Network Toronto Ontario Canada
| | - Jiandong Su
- Centre for Prognosis Studies in Rheumatic Diseases Toronto Lupus Clinic University Health Network Toronto Ontario Canada
| | - Murray B Urowitz
- Centre for Prognosis Studies in Rheumatic Diseases Toronto Lupus Clinic University Health Network Toronto Ontario Canada
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35
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Mejía-Vilet JM, Ayoub I. The Use of Glucocorticoids in Lupus Nephritis: New Pathways for an Old Drug. Front Med (Lausanne) 2021; 8:622225. [PMID: 33665199 PMCID: PMC7921306 DOI: 10.3389/fmed.2021.622225] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022] Open
Abstract
Glucocorticoids therapy has greatly improved the outcome of lupus nephritis patients. Since their discovery, their adverse effects have counterbalanced their beneficial anti-inflammatory effects. Glucocorticoids exert their effects through both genomic and non-genomic pathways. Differential activation of these pathways is clinically relevant in terms of benefit and adverse effects. Ongoing aims in lupus nephritis treatment development focus on a better use of glucocorticoids combined with immunosuppressant drugs and biologics. Newer regimens aim to decrease the peak glucocorticoid dose, allow a rapid glucocorticoid tapering, and intend to control disease activity with a lower cumulative glucocorticoid exposure. In this review we discuss the mechanisms, adverse effects and recent strategies to limit glucocorticoid exposure without compromising treatment efficacy.
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Affiliation(s)
- Juan M Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico
| | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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36
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Tamirou F, Houssiau FA. Management of Lupus Nephritis. J Clin Med 2021; 10:jcm10040670. [PMID: 33572385 PMCID: PMC7916202 DOI: 10.3390/jcm10040670] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/24/2022] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of systemic lupus erythematosus. The main goal of the management of LN is to avoid chronic kidney disease (CKD). Current treatment strategies remain unsatisfactory in terms of complete renal response, prevention of relapses, CKD, and progression to end-stage kidney disease. To improve the prognosis of LN, recent data suggest that we should (i) modify our treat-to-target approach by including, in addition to a clinical target, a pathological target and (ii) switch from conventional sequential therapy to combination therapy. Here, we also review the results of recent controlled randomized trials.
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37
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Ruiz-Irastorza G, Bertsias G. Treating systemic lupus erythematosus in the 21st century: new drugs and new perspectives on old drugs. Rheumatology (Oxford) 2021; 59:v69-v81. [PMID: 33280011 PMCID: PMC7719039 DOI: 10.1093/rheumatology/keaa403] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/05/2020] [Indexed: 12/14/2022] Open
Abstract
Besides treating acute flares, the management of SLE should aim at preventing organ damage accrual and drug-associated harms, improving health-related quality of life and prolonging survival. At present, therapy is based on combinations of antimalarials (mainly HCQ), considered the backbone of SLE treatment, glucocorticoids and immunosuppressive drugs. However, these regimens are not universally effective and a substantial degree of damage can be caused by exposure to glucocorticoids. In this review we provide a critical appraisal of the efficacy and safety of available treatments as well as a brief discussion of potentially novel compounds in patients with SLE. We emphasize the use of methylprednisolone pulses for moderate–severe flares, followed by low–moderate doses of oral prednisone with quick tapering to maintenance doses of ≤5 mg/day, as well as the prompt institution of immunosuppressive drugs in the setting of severe disease but also as steroid-sparing agents. Indications for the use of biologic agents, namely belimumab and rituximab, in refractory or organ-threatening disease are also presented. We conclude by proposing evidence- and experience-based treatment strategies tailored to the clinical scenario and prevailing organ involvement that can aid clinicians in managing this complex disease.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Internal Medicine Department, Biocruces Bizkaia Health Research Institute, University of the Basque Country, Barakaldo, Bizkaia, Bilbao, Spain
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School and University Hospital of Iraklio, Iraklio, Greece
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38
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Andrade SDO, Julio PR, Nunes de Paula Ferreira D, Appenzeller S. Predicting lupus flares: epidemiological and disease related risk factors. Expert Rev Clin Immunol 2021; 17:143-153. [PMID: 33393397 DOI: 10.1080/1744666x.2020.1865156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder, characterized by a relapsing and remitting pattern of disease activity in majority of the patients. Areas covered: This narrative review provides an overview of flare definition, major flare mimics, and the burden of flares in SLE. The authors highlight epidemiology and disease-related risk factor for flares and discuss strategies to reduce flares in SLE. Articles were selected from Pubmed searches conducted between June 2020 and September 2020. Expert opinion: Prolonged clinical remission is observed in approximately 20% of SLE patients flare over the course of the disease. Studies have shown that low disease activity is a good target in SLE, with similar risk of flares, mortality, and quality of life when compared to patients in remission. Clinical and immunological features have shown inconsistent results to identify patients at risk of flares in different cohorts. Cytokine, in serum and urine, has shown promising results to predict flares. However to be useful in clinical practice, they have to be simple, easy, and cost-effective. Future efforts in this direction will allow a more personalized treatment plan for SLE patients, reducing the burden associated with flares.
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Affiliation(s)
- Samuel de Oliveira Andrade
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science-University of Campinas, Brazil.,Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil
| | - Paulo Rogerio Julio
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil
| | - Diego Nunes de Paula Ferreira
- Graduate Student at Child and Adolescent Health Program- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
| | - Simone Appenzeller
- Autoimmunity Lab- School of Medical Science- University of Campinas, Brazil.,Rheumatology Unit-Department of Medicine School of Medical Sciences and University of Campinas (UNICAMP), São Paulo, Brazil
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39
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Morales E, Galindo M, Trujillo H, Praga M. Update on Lupus Nephritis: Looking for a New Vision. Nephron Clin Pract 2020; 145:1-13. [PMID: 33147587 DOI: 10.1159/000511268] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022] Open
Abstract
Lupus nephritis (LN) is one of the most common manifestations of systemic lupus erythematosus (SLE), affecting approximately 40% of patients with lupus. It represents a major risk factor for morbidity and mortality, and 10% of patients with LN will develop end-stage kidney disease (ESKD). Therefore, there are a number of areas for improvement in the field of LN such as the search for new clinical biomarkers with a more accurate correlation with lupus activity and the redefinition of the histological classification into different subgroups in order to guide a personalized treatment. Although the role of protocol repeat kidney biopsies in LN is controversial, recent publications suggest that repeat histological assessment can be useful in guiding therapeutic decisions that may yield toward precision medicine. In the last decade, LN therapy has remained largely unchanged, with a probability of achieving complete or partial remission not exceeding 60-70%. Thus, optimization of old treatment strategies and search for new agents are urgently needed in order to improve outcomes such as mortality or development of ESKD. Future trials should focus in addressing unanswered issues such as the appropriate dose and duration of immunosuppressive treatment, timing of steroid withdrawal, and drug toxicity. In addition, data are still lacking regarding pregnancy and kidney transplantation in LN and knowledge about these important areas is essential for the management of a subset of patients with SLE. In summary, several major gaps are still present in the therapeutic approach and follow-up of patients with LN. The development of new clinical trial designs will be crucial in the search to improve long-term outcomes.
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Affiliation(s)
- Enrique Morales
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain, .,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain,
| | - Maria Galindo
- Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Rheumatology, University Hospital "12 de Octubre", Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain.,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain.,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, Complutense University of Madrid, Madrid, Spain
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40
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Yates DJ, Mon SY, Oh Y, Okano S, Manickam V, Soden M, Kubler P, Ranganathan D. Multicentre retrospective cohort study assessing the incidence of serious infections in patients with lupus nephritis, compared with non-renal systemic lupus erythematosus. Lupus Sci Med 2020; 7:7/1/e000390. [PMID: 32963113 PMCID: PMC7509980 DOI: 10.1136/lupus-2020-000390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 11/26/2022]
Abstract
Objectives The incidence of serious infections is poorly defined in patients with lupus nephritis (LN). It is also unclear if LN influences risk of serious infections in a longitudinal analysis. The aim of this study was to determine the incidence of serious infections in patients with SLE and LN, compared with patients with SLE without LN. Methods A multicentre retrospective cohort study was conducted. Patients with LN identified at two tertiary centres were matched where possible with age and gender-matched patients with SLE without LN. Any infection requiring inpatient admission, occurring in the 6 months following index clinical visit, was considered serious. Cox regression was employed to investigate the association between risk of serious infection and LN status, and other relevant covariates. Results A total of 173 patients were included within the analysis (n=87 LN, n=86 SLE only). A total of 9.2% (n=8) of patients with LN experienced at least one serious infection within the study period, compared with 5.8% (n=5) of patients without LN, equivalent to 19.5 and 12.0 infections per 100 patient-years with and without LN, respectively. Univariable and multivariable analyses found no significant increased risk of serious infection in patients with LN versus controls (HR 1.61; 95% CI 0.53 to 4.92 and adjusted HR (aHR) 0.91; 95% CI 0.27 to 3.06, respectively). Increased prednisone dose and modified SLE comorbidity index were strongly associated with serious infection (aHR (per 5 mg) 1.21; 95% CI 1.07 to 1.37; p=0.003 and aHR 1.13; 95% CI 1.02 to 1.25; p=0.018, respectively). Conclusions In this cohort, adjusting for cofactors, the presence of LN alone does not appear to increase the risk of serious infections compared with patients with SLE without LN. However, increased prednisone dose at baseline visit and increasing comorbidity were independently associated with the incidence of serious infection.
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Affiliation(s)
- Drew Joseph Yates
- Rheumatology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Saw Yu Mon
- Renal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Yumi Oh
- Internal Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Satomi Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Valli Manickam
- Renal Medicine, The Townsville Hospital, Townsville, Queensland, Australia
| | - Muriel Soden
- Rheumatology, The Townsville Hospital, Townsville, Queensland, Australia
| | - Paul Kubler
- Rheumatology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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41
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Porta S, Danza A, Arias Saavedra M, Carlomagno A, Goizueta MC, Vivero F, Ruiz-Irastorza G. Glucocorticoids in Systemic Lupus Erythematosus. Ten Questions and Some Issues. J Clin Med 2020; 9:jcm9092709. [PMID: 32839376 PMCID: PMC7563630 DOI: 10.3390/jcm9092709] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022] Open
Abstract
Since the discovery of glucocorticoids (GCs), their important anti-inflammatory effect, rapid mechanism of action, low cost, and accessibility have made them one of the mainstays of treatment for Systemic lupus erythematosus (SLE). Although their use has allowed controlling the disease and reducing acute mortality in severe conditions, the implementation of a scheme based on high doses for long periods has inevitably been accompanied by an increase in adverse effects and infections, including long-term damage. The objective of this review is to answer some important questions that may arise from its use in daily clinical practice, and to propose a paradigm based on the use of methylprednisolone pulses followed by medium-low doses and a rapid decrease of prednisone.
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Affiliation(s)
- Sabrina Porta
- Rheumatology Department, Hospital JM Ramos Mejía, Buenos Aires 1221, Argentina; (S.P.); (M.A.S.)
| | - Alvaro Danza
- Department of Internal Medicine, Faculty of Medicine, Universidad de la República, Montevideo 11000, Uruguay; (A.D.); (A.C.)
| | - Maira Arias Saavedra
- Rheumatology Department, Hospital JM Ramos Mejía, Buenos Aires 1221, Argentina; (S.P.); (M.A.S.)
| | - Adriana Carlomagno
- Department of Internal Medicine, Faculty of Medicine, Universidad de la República, Montevideo 11000, Uruguay; (A.D.); (A.C.)
| | | | - Florencia Vivero
- Autoimmune Disease Unit, Hospital Privado de Comunidad, Mar del Plata B7600, Argentina;
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, BioCruces Bizkaia Health Research Institute, Cruces Univeristy Hospital, 48903 Bizkaia, Spain
- University of the Basque Country, 48940 Leioa, Spain
- Correspondence:
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42
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Ruiz-Irastorza G, Ugarte A, Ruiz-Arruza I, Khamashta M. Seventy years after Hench’s Nobel prize: revisiting the use of glucocorticoids in systemic lupus erythematosus. Lupus 2020; 29:1155-1167. [DOI: 10.1177/0961203320930099] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 1950, Hench, Kendall and Reichstein were awarded with the Nobel Prize in Physiology and Medicine for the isolation and first therapeutic use of glucocorticoids. Since then, they have become one of the main agents in the treatment of systemic lupus erythematosus (SLE). The use of high-dose oral glucocorticoids (usually 1 mg/kg/day of prednisone equivalent) have become the rule for treating moderate to severe lupus activity. In addition, tapering schemes have not been well defined, all this leading to prolonged exposures to potentially damaging amounts of glucocorticoids. Several studies have shown that glucocorticoids are a major cause of toxicity in SLE in a dose-dependent manner, with prolonged doses greater than 7.5 mg/day being associated with damage accrual. Thus, there is an urgent need for different therapeutic schedules that can achieve a rapid and durable control of lupus activity while reducing the many unwanted effects of glucocorticoids. Recent data show that pulses of methyl-prednisolone are an effective first-line therapy to treat lupus flares (not only severe ones) without major short or long-term toxicity and allowing a reduction in oral prednisone doses. Universal use of hydroxychloroquine – always recommended, infrequently accomplished – and early therapy with immunosuppressive drugs also help control SLE and reduce prednisone load. Results from observational studies confirm the more rapid achievement of remission and the reduction of long-term damage using these combination schedules with reduced prednisone doses. Seventy years after their first therapeutic use, we are learning to use glucocorticoids in a more efficient and safe manner.
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Affiliation(s)
- Guillermo Ruiz-Irastorza
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Amaia Ugarte
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Ioana Ruiz-Arruza
- Hospital Universitario Cruces, BioCruces Bizkaia Health Research Institute, University of the Basque Country, Spain
| | - Munther Khamashta
- Department of Women and Children’s Health, St Thomas Hospital, London
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43
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Mok CC, Tse SM, Chan KL, Ho LY. Prevalence and risk factors of herpes zoster infection in patients with biopsy proven lupus nephritis undergoing immunosuppressive therapies. Lupus 2020; 29:836-844. [PMID: 32408851 DOI: 10.1177/0961203320923739] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To study the prevalence of herpes zoster infection in patients with biopsy-confirmed lupus nephritis undergoing immunosuppressive therapies. METHODS Patients who had histologically active lupus nephritis between 2004 and 2018 were retrospectively reviewed. Clinical and laboratory data at baseline and six months post-therapy were collected. The incidence of herpes zoster reactivation within two years of lupus nephritis treatment was calculated. Risk factors for herpes zoster reactivation were studied by logistic regression. RESULTS Patients (N = 251) with 311 episodes of lupus nephritis were studied (92% women; age 34.2 ± 14.2 years; histological classes III/IV ± V (69%)). Within two years of therapy, 55 (18%) episodes of lupus nephritis were complicated by herpes zoster infection (incidence 8.84/100 patient-years). Fourteen episodes (25%) of herpes zoster were treated by intravenous anti-viral drugs in hospital but disseminated disease or mortality was not reported. Significant post-herpetic neuralgia developed in 9% of the episodes. Patients with herpes zoster reactivation, compared with those without, were more likely to have first-time renal disease and a shorter systemic lupus erythematosus duration at lupus nephritis than those without. Disease activity, treatment response and other clinical/laboratory parameters were not significantly different between patients with and without herpes zoster reactivation. Herpes zoster-infected patients had been treated with a significantly higher dose of prednisolone as induction therapy. Logistic regression revealed that first-time renal disease, peak daily mycophenolate mofetil dose and cumulative cyclophosphamide dose during induction therapy were significantly associated with herpes zoster reactivation. CONCLUSIONS Herpes zoster reactivation is common in lupus nephritis patients but unpredictable from clinical parameters. Although adverse outcomes of herpes zoster infection are uncommon, using the minimally effective doses of mycophenolate mofetil and cyclophosphamide during induction therapy may help reduce the risk of herpes zoster infection.
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Affiliation(s)
- Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR China
| | - Sau Mei Tse
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR China
| | - Kar Li Chan
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR China
| | - Ling Yin Ho
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR China
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44
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Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, Boletis J, Frangou E, Houssiau FA, Hollis J, Karras A, Marchiori F, Marks SD, Moroni G, Mosca M, Parodis I, Praga M, Schneider M, Smolen JS, Tesar V, Trachana M, van Vollenhoven RF, Voskuyl AE, Teng YKO, van Leew B, Bertsias G, Jayne D, Boumpas DT. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis 2020; 79:713-723. [PMID: 32220834 DOI: 10.1136/annrheumdis-2020-216924] [Citation(s) in RCA: 387] [Impact Index Per Article: 96.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours with (near-)normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Frederic A Houssiau
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jane Hollis
- Lupus nurse specialist, Addenbrooke's Hospital, Cambridge, UK
| | - Adexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Stephen D Marks
- University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Manuel Praga
- Nephrology Department, Research Institute Hospital Universitario 12 de Octubre (i+12), Department of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Duesseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, First Pediatric Clinic, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Y K Onno Teng
- Centre of expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece .,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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45
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Pepper RJ, McAdoo SP, Moran SM, Kelly D, Scott J, Hamour S, Burns A, Griffith M, Galliford J, Levy JB, Cairns TD, Gopaluni S, Jones RB, Jayne D, Little MA, Pusey CD, Salama AD. A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology (Oxford) 2019; 58:260-268. [PMID: 30239910 DOI: 10.1093/rheumatology/key288] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 01/03/2023] Open
Abstract
Objectives Glucocorticoids (GCs) are a mainstay of treatment for patients with ANCA-associated vasculitis (AAV) but are associated with significant adverse effects. Effective remission induction in severe AAV using extremely limited GC exposure has not been attempted. We tested an early rapid GC withdrawal induction regimen for patients with severe AAV. Methods Patients with active MPO- or PR3-ANCA vasculitis or ANCA-negative pauci-immune glomerulonephritis were included. Induction treatment consisted of two doses of rituximab, 3 months of low-dose CYC and a short course of oral GC (for between 1 and 2 weeks). Clinical, biochemical and immunological outcomes as well as adverse events were recorded. Results A total of 49 patients were included, with at least 12 months of follow-up in 46. All patients achieved remission, with decreases observed in creatinine, proteinuria, CRP, ANCA level and BVAS. Three patients requiring dialysis at presentation became dialysis independent. Two patients required the introduction of maintenance GC for treatment of vasculitis. Overall outcomes were comparable to those of two matched cohorts (n = 172) from previous European Vasculitis Society (EUVAS) trials, but with lower total exposure to CYC and GCs (P < 0.001) and reduced rates of severe infections (P = 0.02) compared with the RITUXVAS (rituximab versus cyclophosphamide in AAV) trial. We found no new cases of diabetes in the first year compared with historic rates of 8.2% from the EUVAS trials (P = 0.04). Conclusion Early GC withdrawal in severe AAV is as effective for remission induction as the standard of care and is associated with reduced GC-related adverse events.
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Affiliation(s)
- Ruth J Pepper
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Stephen P McAdoo
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah M Moran
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Dearbhla Kelly
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Jennifer Scott
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland
| | - Sally Hamour
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Aine Burns
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
| | - Megan Griffith
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jack Galliford
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy B Levy
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas D Cairns
- Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | | | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Tallaght Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, Trinity College, Dublin, Ireland
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, London, UK.,Vasculitis Clinic, Imperial College Healthcare NHS Trust, London, UK
| | - Alan D Salama
- University College London Centre for Nephrology, Royal Free Hospital, London, UK
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46
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Smith EMD, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: Update on clinical presentation, pathophysiology and treatment options. Clin Immunol 2019; 209:108274. [PMID: 31678365 DOI: 10.1016/j.clim.2019.108274] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 12/25/2022]
Abstract
Juvenile-onset systemic lupus erythematosus (jSLE) accounts for up to 20% of all SLE patients. Key differences between juvenile- and adult-onset (aSLE) disease include higher disease activity, earlier development of damage, and increased use of immunosuppressive treatment in jSLE suggesting (at least partial) infectivity secondary to variable pathomechanisms. While the exact pathophysiology of jSLE remains unclear, genetic factors, immune complex deposition, complement activation, hormonal factors and immune cell dysregulation are involved to variable extents, promising future patient stratification based on immune phenotypes. Though less effective and potentially toxic, jSLE patients are treated based upon evidence from studies in aSLE cohorts. Here, age-specific clinical features of jSLE, underlying pathomechanisms, treatment options and disease outcomes will be addressed. Future directions to improve the care of jSLE patients, including implementation of the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) recommendations, biomarkers, treat to target and personalized medicine approaches are discussed.
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Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Angela Midgley
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK
| | - Michael William Beresford
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Christian Michael Hedrich
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
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47
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Bharati J, Rathi M, Ramachandran R, Sharma A, Kumar V, Kohli HS, Gupta KL. Comparison of Two Steroid Regimens in Induction Therapy of Proliferative Lupus Nephritis: A Randomized Controlled Trial. Indian J Nephrol 2019; 29:373-375. [PMID: 31571750 PMCID: PMC6755920 DOI: 10.4103/ijn.ijn_299_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Post graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Department of Nephrology, Post graduate Institute of Medical Education and Research, Chandigarh, India
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48
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Pimentel-Quiroz VR, Ugarte-Gil MF, Harvey GB, Wojdyla D, Pons-Estel GJ, Quintana R, Esposto A, García MA, Catoggio LJ, Cardiel MH, Barile LA, Amigo MC, Sato EI, Bonfa E, Borba E, Lavras Costallat LT, Neira OJ, Massardo L, Guibert-Toledano M, Chacón-Díaz R, Alarcón GS, Pons-Estel BA. Factors predictive of serious infections over time in systemic lupus erythematosus patients: data from a multi-ethnic, multi-national, Latin American lupus cohort. Lupus 2019; 28:1101-1110. [DOI: 10.1177/0961203319860579] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aim The aim of this study was to identify factors predictive of serious infections over time in patients with systemic lupus erythematosus (SLE). Methods A multi-ethnic, multi-national Latin American SLE cohort was studied. Serious infection was defined as one that required hospitalization, occurred during a hospitalization or led to death. Potential predictors included were sociodemographic factors, clinical manifestations (per organ involved, lymphopenia and leukopenia, independently) and previous infections at baseline. Disease activity (SLEDAI), damage (SLICC/ACR Damage Index), non-serious infections, glucocorticoids, antimalarials (users and non-users), and immunosuppressive drugs use; the last six variables were examined as time-dependent covariates. Cox regression models were used to evaluate the predictors of serious infections using a backward elimination procedure. Univariable and multivariable analyses were performed. Results Of the 1243 patients included, 1116 (89.8%) were female. The median (interquartile range) age at diagnosis and follow-up time were 27 (20–37) years and 47.8 (17.9–68.6) months, respectively. The incidence rate of serious infections was 3.8 cases per 100 person-years. Antimalarial use (hazard ratio: 0.69; 95% confidence interval (CI): 0.48–0.99; p = 0.0440) was protective, while doses of prednisone >15 and ≤60 mg/day (hazard ratio: 4.18; 95 %CI: 1.69–10.31; p = 0.0019) and >60 mg/day (hazard ratio: 4.71; 95% CI: 1.35–16.49; p = 0.0153), use of methylprednisolone pulses (hazard ratio: 1.53; 95% CI: 1.10–2.13; p = 0.0124), increase in disease activity (hazard ratio: 1.03; 95% CI: 1.01–1.04; p = 0.0016) and damage accrual (hazard ratio: 1.22; 95% CI: 1.11–1.34; p < 0.0001) were predictive factors of serious infections. Conclusions Over time, prednisone doses higher than 15 mg/day, use of methylprednisolone pulses, increase in disease activity and damage accrual were predictive of infections, whereas antimalarial use was protective against them in SLE patients.
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Affiliation(s)
- V R Pimentel-Quiroz
- Department of Rheumatology, Hospital Nacional ‘Guillermo Almenara Irigoyen’ Essalud, Lima, Peru
| | - M F Ugarte-Gil
- Department of Rheumatology, Hospital Nacional ‘Guillermo Almenara Irigoyen’ Essalud, Lima, Peru
- Universidad Científica del Sur, Lima, Peru
| | - GB Harvey
- Escuela de Estadística, Facultad de Ciencias Económicas y Estadística, Universidad Nacional de Rosario, Rosario, Argentina
| | - D Wojdyla
- GLADEL consultant, Rosario, Argentina
| | - G J Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
- Servicio de Reumatología, Hospital Provincial de Rosario, Rosario, Argentina
| | - R Quintana
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
- Servicio de Reumatología, Hospital Provincial de Rosario, Rosario, Argentina
| | - A Esposto
- Servicio de Infectología, Hospital Interzonal General de Agudos ‘General San Martín’, La Plata, Argentina
| | - M A García
- Servicio de Infectología, Hospital Interzonal General de Agudos ‘General San Martín’, La Plata, Argentina
| | - L J Catoggio
- Servicio de Reumatolgía, Hospital Italiano and Fundación ‘Dr. Pedro M. Catoggio para el Progreso de la Reumatología’, Buenos Aires, Argentina
| | - M H Cardiel
- Centro de Investigación Clínica de Morelia, Morelia, Michoacán, Mexico
| | - L A Barile
- Servicio de Reumatología, Hospital Ángeles del Pedregal, Ciudad de México, Mexico
| | - M -C Amigo
- Centro Médico ABC, Ciudad de México, Mexico
| | - E I Sato
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - E Bonfa
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - E Borba
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - L T Lavras Costallat
- Departamento de Clínica Médica, Faculdade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
| | - O J Neira
- Sección de Reumatología, Hospital del Salvador, Universidad de Chile. Unidad de Reumatología, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - L Massardo
- Centro de Biología Celular y Biomedicina, Facultad de Medicina y Ciencia, Universidad San Sebastián, Santiago, Chile
| | | | - R Chacón-Díaz
- Servicio de Reumatología, Policlínica Méndez Gimón, Caracas, Venezuela
| | - G S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - B A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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49
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Dall’Era M, Solomons N, Federico R, Truman M. Comparison of standard of care treatment with a low steroid and mycophenolate mofetil regimen for lupus nephritis in the ALMS and AURA studies. Lupus 2019; 28:591-596. [DOI: 10.1177/0961203319842924] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Lupus nephritis is the most common organ-threatening manifestation of systemic lupus erythematosus. The current standard of care for patients is treatment with a combination of steroids plus either mycophenolate mofetil (MMF) or cyclophosphamide. However, these medications are associated with considerable toxicity and suboptimal efficacy. This retrospective propensity analysis of data from 63 matched patients enrolled in two of the largest active lupus nephritis controlled trials, ALMS and AURA, suggests that the high dose regimen of MMF and steroids as described in the 2012 American College of Rheumatology lupus nephritis guidelines may not be necessary in all lupus nephritis patients. A lower dose regimen may result in better long-term safety, including a reduction in lymphoproliferative disorders, skin cancers and steroid related side effects, without compromising efficacy. An ongoing randomized controlled double-blind phase 3 study, AURORA (NCT03021499), is investigating renal response in 358 patients randomized to receive a low dose regimen containing voclosporin, MMF and steroid therapy as used in the AURA trial. It is anticipated that the AURORA study and its blinded two-year extension will provide important long-term outcome data.
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Affiliation(s)
- M Dall’Era
- University of California, San Francisco, USA
| | - N Solomons
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
| | - R Federico
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
| | - M Truman
- Aurinia Pharmaceuticals, Inc., Victoria, Canada
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50
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Kronbichler A, Brezina B, Gauckler P, Quintana LF, Jayne DRW. Refractory lupus nephritis: When, why and how to treat. Autoimmun Rev 2019; 18:510-518. [PMID: 30844548 DOI: 10.1016/j.autrev.2019.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Refractory lupus nephritis indicates an inadequate response to lupus nephritis therapy. It implies persisting or worsening disease activity despite therapy, but the definition is complicated by the parameters of response, proteinuria and renal function, that do not discriminate clearly between activity and irreversible damage. Understanding the causes of refractory disease and developing treatment strategies is important because these patients are more likely to develop poor outcomes, especially end stage renal disease. This review explores current concepts and definitions of refractory disease and summarises treatment approaches that have been used in observational cohort studies and case series. We highlight the importance of optimising adherence to the prescribed immunosuppressive and supportive measures and avoidance of diagnostic delay. Treatment options include higher dose glucocorticoid, switching between cyclophosphamide and mycophenolate acid derivates, or addition of rituximab, the latter potentially in combination with belimumab. Less evidence supports extracorporeal treatment (plasma exchange or immunoadsorption), calcineurin inhibitors (cyclosporine A or tacrolimus), intravenous immunoglobulin and stem cell transplantation. Improvements in understanding what refractory disease is and how definitions can be integrated into treatment pathways has the potential to enhance lupus nephritis outcomes.
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Affiliation(s)
- Andreas Kronbichler
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Biljana Brezina
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Luis F Quintana
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Hills Road, CB2 0QQ, Cambridge, Cambridge University Hospitals, United Kingdom; Department of Medicine, University of Cambridge, CB2 0QQ Cambridge, United Kingdom.
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