SAN FRANCISCO – Most patients with systemic lupus nephritis should be on hydroxychloroquine, according to guidelines on the management of lupus nephritis to be issued by the American College of Rheumatology.
Renal involvement increases mortality in patients with systemic lupus erythematosus (SLE). About 95% of patients with lupus survive 10 years. That was not true 25 years ago; mortality was much worse. "Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn, division chief and professor of rheumatology at the University of California, Los Angeles.
However, when the lupus patient has nephritis, survival drops to 85% for all races combined. For blacks and Hispanics, the 10-year year survival is even worse.
Guidelines on the management of lupus nephritis have been developed by a committee of the American College of Rheumatology, which Dr. Hahn chairs. Those guidelines will be published after review by several ACR committees.
Hydroxychloroquine is one of the reasons that outcomes have improved so much for patients with SLE. Data from a study of 518 patients who had SLE for less than 5 years showed that 56% of them were on hydroxychloroquine at the time of enrollment, said Dr. Hahn at the Perspectives in Rheumatic Diseases 2011 meeting.
"Every now and then in rheumatology we make some progress. This is such progress," said Dr. Bevra Hahn.
Use of hydroxychloroquine was associated with a reduced risk for developing new damage (hazard ratio, 0.73; 95% confidence interval, 0.52-1.00; P = .05). Of note, patients on hydroxychloroquine who had no damage at study entry had a statistically significant decrease in the risk of developing any organ damage (HR, 0.55; 95% CI, 0.34-0.87; P = .0111), whereas those on hydroxychloroquine who had damage at study entry did not (HR, 1.106; 95% CI, 0.70-1.74; P = .6630) (Arthritis Rheum. 2005;52:1473-80).
The big stick in the management of lupus is glucocorticoids. Rheumatologists have known since 1985 that high-dose intravenous glucocorticoids save lives. Intravenous cyclophosphamide preserved renal function better than steroids or steroids plus azathioprine in patients with class IV lupus nephritis. It became the standard of care for close to 10 years, based on research done at the National Institutes of Health (Arthritis Rheum. 2002;46:2121-31).
Because of its side effects, "patients absolutely despise cyclophosphamide" and it takes a long time to work, noted Dr. Hahn at the meeting, which was sponsored by Skin Disease Education Foundation.
However, mycophenolate seems to produce outcomes that are comparable to those from cyclophosphamide. Findings from a study of 364 patients with acute lupus nephritis showed that, overall, 6 months of induction treatment with mycophenolate worked as well as cyclophosphamide in whites. However, blacks and Hispanics have a significantly lower response to cyclophosphamide than to mycophenolate (J. Am. Soc. Nephrol. 2009;20:1103-12).
Dr. Hahn urged the audience to keep in mind that mycophenolate is a teratogen, but added that in all other respects the two agents are equally safe (J. Rheumatol. 2011;38:69-78).
Dr. Hahn reported financial relationships with Abbott, Aspreva, Teva, and UCB. SDEF and this news organization are owned by Elsevier.