Liz Lightstone, MBBS, PhD, FRCP, professor of renal medicine for the Faculty of Medicine, Imperial College London, spoke on issues regarding the current standard of care for lupus nephritis, including steroid overuse, pregnancy, and dose-related toxicity.
There is an overuse of steroids in the current standard of care for lupus nephritis, as well as pregnacy and fertility concerns that female patients, often of childbearing age, should be aware of, said Liz Lightstone, MBBS, PhD, FRCP, professor of renal medicine for the Faculty of Medicine, Imperial College London.
Can you speak on any issues regarding the current standard of care for lupus nephritis?
So, the current standard of care would either be a combination of steroids with mycophenolate mofetil or steroids with low-dose cyclophosphamide. They're both pretty effective. A few patients never tolerate mycophenolate—they feel nauseated, they feel horrible—but it's usually well tolerated. It damages fetuses, so it's teratogenic. So, it's a real problem.
This is a disease that affects women of childbearing age. They shouldn't get pregnant when they've got active lupus nephritis anyway, but you have to tell them that even when we've got them into remission, they've got to wait, they've got to change to a new drug, usually azathioprine, and wait and see that they're okay on that and then they can change.
Cyclophosphamide is also teratogenic, but also can affect fertility. With the doses we usually use it, not so much and we use ovarian protection to reduce that. But that's an intravenous preparation, it can make people feel a bit sick. It is very effective, but it has a dose-related toxicity so you can't use it repeatedly. You can do a cycle. If they go into remission, fine, then they’re going to go on to [mycophenolate mofetil] for maintenance.
So, there's a real issue around pregnancy and fertility. Patients just don't like taking tablets, and in aiming to minimize steroids, a lot of the current regimens still have a lot of steroids in. The KDIGO [Kidney Disease Improving Global Outcomes] guideline from last year said, if they're in remission for a year, wean them off completely. I would argue you could wean them off much sooner than that. But there's still far too much steroid in the current regimens.