Lupus Nephritis: Assessing Response to Novel Therapy

Fotios Koumpouras, MD, FACR: Ron, how long do you treat your patients who had lupus nephritis but otherwise had done well in induction and maintenance of remission? Indefinitely? Five years?

Ronald van Vollenhoven, Prof. PhD: That’s a difficult question. Why do I get the difficult questions? Let me see.

Fotios Koumpouras, MD, FACR: I’m sorry. I’ll tell you what I do. The traditional teaching was that if you withdrew immunosuppression before 3 years, there seemed to have been a fair amount of relapse. But if you had this treatment for 3 to 5 years and you withdrew—I can’t quote the data—you seemed to have a more suppressive effect. For me, if they’re serologically active, and certainly if they’re young, I’m in favor of chronic suppression of the disease because it’s a genetic disease. The disease comes down to the genes in many instances and the response to something that I’m not sure would forever go away. You’ve seen these withdrawal trials—your patients with lupus need ongoing therapy. But when do you need the therapy? It’s not clear that they’re chronically active. I’m in the favor of treating them long term, certainly for a good 10 years or so. Maybe if they’ve had quiescent disease and we’re tapering, but usually I treat long term.

Ronald van Vollenhoven, Prof. PhD: I agree with you, especially if you have serological activity. The patient is feeling fine with no manifestations, but if they have anti-DNA, a low complement, or other strong associated antibodies, then I’d be very careful in tapering or stopping. But if the patient has been in remission and the serology looks good, I might be willing to try it. You have to have the conversation with the patient. Is this going to be totally safe? You can never promise that. There’s always a risk. But you can give them the promise that as soon as something starts happening, you’ll be there for them and hope that it can work. Patients do sometimes feel they want to give that possibility a chance, to be free of treatment. That happens also. But I’d be very careful if I saw serological activity.

Fotios Koumpouras, MD, FACR: We’re treating similarly. And we have guidelines by your group, the EULAR [European Alliance of Associations for Rheumatology], from 2019, for the treatment of lupus nephritis. They’re very helpful for the general rheumatologist who may not be as familiar with this. If you look at the guidelines, there’s emphasis on the adjunctive treatment, reducing steroids. What are the concepts? What are the goals? That can be very helpful even to folks who treat lupus. But as you know from the trials, not everyone with lupus nephritis gets better. You can give them all these medications, your drug combination therapies, and you’re getting about 40% of the patient’s complete response. That means 60% of the patients still have some activity.

Transcript Edited for Clarity