Michelle A Petri
SAN DIEGO — Rheumatologists treating patients with lupus nephritis should make a concerted effort to reduce or avoid use of NSAIDs and other nephrotoxic drugs in order to improve long-term outcomes, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
“How much prednisone should we be using to treat lupus nephritis? As little as possible!” Michelle A Petri, MD, MPH, director of the John Hopkins Lupus Center, told attendees. “My lupus twin in the United Kingdom, nephrologist Liz Lightstone, PhD, MRCP, uses zero oral prednisone. One might ask ‘How can you get away with zero oral prednisone for lupus nephritis?’ She uses rituximab plus mycophenolate. Although it is not a randomized clinical trial — because she could not get funding — it is her open label experience.”
In their pilot steroid-avoiding protocol of rituximab (Rituxan, Genentech) plus maintenance therapy of mycophenolate mofetil — known as “rituxilup” — Lightstone and colleagues demonstrated that oral steroids could be safely avoided in the treatment of lupus nephritis while achieving partial or complete remission in 90% of patients.
“Even in the recent lupus nephritis trials, prednisone has been quite limited,” Petri noted. “And none of this 1 mg per kg stuff.”
In their phase 2, multicenter randomized trial of voclosporin vs. placebo in combination with mycophenolate mofetil and low-dose oral corticosteroids for induction of remission in lupus nephritis, Rovin and colleagues limited the prednisone dose to only 20 mg.
“If a patient has rapidly progressing glomerulonephritis, even I have been known to pour on the steroids,” Petri said. “But if the patient has a stable creatinine, why do you have to give 60 mg? You don’t. If it’s a lesser lesion, you don’t have to give 60 mg. Please start to think about limiting prednisone for lupus nephritis.”
While Petri emphasized the importance of not allowing a lupus patient to flare, she also highlighted the renal toxicity of commonly used NSAIDs and other known nephrotoxic agents. Although it is important for patients to also avoid CT dyes, Petri admitted the difficulty in barring its use: “Every time something serious happens and the patient is admitted to the ER, they are going to end up with a CT with contrast.”
Petri advised rheumatologists to listen to the nephrologists and make every attempt to “minimize the nephrotoxic agents to which our patients are exposed.”
“The lesson nephrologists want to teach us is that the only way to keep a patient off of dialysis is if they are a complete renal responder,” Petri said. “If they are partial responder, they are going to end up on dialysis; it may take them longer but they are going to get there. Renal remission is our goal.”– by Robert Stott
- Petri MA. Treatment Updates in SLE. Presented at: Congress of Clinical Rheumatology West; September 26-29, 2019; San Diego.
- Condon et al. Ann Rheum Dis. 2013;doi:10.1136/annrheumdis-2012-202844.
- Rovin BH et al. Kidney Int. 2019;doi:10.1016/j.kint.2018.08.025.
Disclosure: Petri reports consulting relationships with Amgen, Boston Pharmaceuticals, Bristol-Myers Squibb, EMD Serono, GlaxoSmithKline, Janssen and Novartis.