Key opinion leaders discuss aspects driving care pathways for patients with lupus nephritis.
Jorge Larranaga, MD: There are many issues involved in seeing patients with lupus disease. Many patients experience delay in care for multiple reasons, including socioeconomic status, insurance, young age, and not seeking attention until it’s too late. But there are some data from Medicaid years ago that say that 1 of 8 patients with lupus nephritis are seen in a hospital setting in a very critical state with rapidly progressive crescentic renal diseases. This has suggested that there’s poor, inadequate interactive collaborative management and transitions of patients’ care among physicians and hospitals.
Furthermore, the percentage of patients who have received immunosuppressive therapy after the diagnosis of lupus nephritis is quite impressive in the sense that 13% of patients get immunosuppressive therapy within 30 days of having a lupus nephritis diagnosis. Roughly 22% of the patients get immunosuppressive therapy at 90 days, and 34% get it 1 year after a lupus nephritis diagnosis. This is clearly unacceptable. These are data from the Medicaid trials. These patients need to be seen [and receive] intravenous [treatment] as urgently as possible. Otherwise, it’s ultimately about renal demise and patient survival.
Alvin Wells, MD, PhD: Many patients with lupus and lupus nephritis utilize a lot of aspects of our medical system. That young female patient with lupus nephritis has to be seen every 3 months by a rheumatologist. She has to get bloodwork. She has to get her urine tested. She’s going to be on several medications to treat her disease. Because of the disease and the medications patients are on, they can have other complications. Patients with lupus nephritis are at increased risk for infections. They can end up with cardiovascular disease. All of those features cost a lot in the medical system, and these patients need to be seen and followed closely.
At my practice, I tell my patients: “If you have a flare of your disease or other or new symptoms, don’t go to the emergency department. Call me. Because I know you and the drugs that you’re on. You know my staff, and we can treat almost everything that can trigger or be associated with a flare.” If a patient is retaining fluid or their blood pressure goes up, we can address that. When a patient is having a fever and a cough, it could be a sign of an infection. We can address that. Even though patients with lupus nephritis use a lot of health care resources, we can mitigate that and minimize how much they use by having them seen on a regular basis in a rheumatology clinic and by us if they have any acute or urgent needs.
If patients with lupus nephritis have disease progression—meaning they aren’t responding to therapy—they require a lot more utilization of health care resources. If you have a patient on multiple drugs to treat their lupus nephritis and they continue to progress—meaning they’re seeing more protein in their urine—there are certain markers in the bloodwork that are going up, and that correlates with some of their other symptoms as well. That patient is going to require more medications to get them under control.
When patients require more medications, we’re going to follow their laboratory values [more frequently than] every 3 or 4 months. I have some patients whom we test every month until we get them under control. Because as we worry about the balance of the benefits of the medicines, I also want to make sure there are no adverse effects of the medication. That’s why these patients have to be followed closely. One pearl I’ll put in a plug for is that even if your patients aren’t able to be seen physically in the clinic, they can take advantage of telemedicine. I can do a telephone call to address their acute or urgent needs. I can do a video visit to talk about different things as well. That’s something we do to keep these patients from using more health care resources.
Transcript edited for clarity.