From the Guidelines
The treatment for lupus nephritis in a 50-year-old woman should involve a combination of mycophenolate mofetil (MMF) or low-dose intravenous cyclophosphamide (CY), both combined with glucocorticoids, as initial induction therapy, followed by long-term maintenance treatment with MMF or azathioprine and low-dose glucocorticoids, as recommended by the 2019 update of the EULAR/ERA-EDTA guidelines 1.
Key Components of Treatment
- Induction therapy with MMF (2-3 g/day) or low-dose CY (500 mg × 6 biweekly doses), combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) for 3-6 months 1
- Maintenance therapy with MMF or azathioprine, and low-dose glucocorticoids (<7.5 mg/day) for at least 3 years 1
- Hydroxychloroquine (200-400 mg/day) should be added throughout treatment to reduce flares, with regular ophthalmological monitoring 1
- Blood pressure control with ACE inhibitors or ARBs to target <130/80 mmHg, to protect kidney function 1
Monitoring and Adjustments
- Regular monitoring of kidney function, urine protein, blood counts, and drug levels to assess response and adjust medications 1
- Assessment for kidney and extra-renal disease activity, and management of comorbidities is recommended 1
- Switch of induction regimens or rituximab may be considered in non-responding disease 1
From the Research
Treatment Options for Lupus Nephritis
The treatment for lupus nephritis in a 50-year-old woman can be guided by the following options:
- Initial treatment: A combination of glucocorticoids with cyclophosphamide, mycophenolate mofetil, or calcineurin inhibitors as first-line options 2
- Induction therapy: Mycophenolate mofetil has been shown to be non-inferior to cyclophosphamide for induction therapy 3
- Maintenance therapy: Mycophenolate mofetil is superior to azathioprine in maintaining a renal response to treatment and preventing relapse 4
- Treatment duration: Subsequent/maintenance therapy of lupus nephritis should continue for at least 3 years to reduce the risk of renal flares 2
Immunosuppressive Therapies
Immunosuppressive therapies have significantly improved long-term outcomes for lupus nephritis, including:
- Cyclophosphamide-based regimens, given concomitantly with corticosteroids, have improved survival significantly 5
- Mycophenolate mofetil, azathioprine, and biologic therapies such as Belimumab, Rituximab, and Abatacept are also used 5
Adjunctive Therapies
Adjunctive therapies, such as optimizing risk factors like proteinuria and hypertension with renin-angiotensin receptor blockade, are crucial in managing lupus nephritis 5
- Hydroxychloroquine may also be used as an adjunctive therapy 5
Individualized Treatment
Management of lupus nephritis should be individualized for each patient based on their risk-benefit profile 6
- The treatment of lupus nephritis is largely determined based on the histological class present on the renal biopsy specimen 6