Potential treatment for lupus nephritis without oral steroids

INTRODUCTION

A small study of a new combination treatment for lupus nephritis that doesn’t include oral steroids has shown encouraging results. If larger studies show similar results, the new combination treatment could help people with this condition avoid the side effects of long-term treatment with high doses of oral steroids.

WHAT DO WE KNOW ALREADY?

Lupus nephritis is inflammation, or swelling, in the kidneys that stops them working properly. It is a serious complication of systemic lupus erythematosus (SLE), an autoimmune disease that can affect different organs and parts of the body. In the UK, up to 60 in 100 adults with SLE are affected by lupus nephritis.

Treating lupus nephritis is not straightforward. The only drugs approved to treat it in the UK are aspirin, a rheumatoid arthritis treatment called hydroxychloroquine, and corticosteroids (usually just called steroids), which can help reduce swelling. But these don’t help everyone. So doctors often prescribe treatments that haven’t been officially approved for people with lupus nephritis, but which work well.

People who have lupus nephritis often have bouts of symptoms, called relapses, that last for weeks or months, which means they need to have treatment for some time. However, taking oral steroids (steroid tablets) for a long time, particularly the high doses needed to treat lupus nephritis, can cause serious side effects and harm.

In this study, researchers looked at using a different combination of medicines to treat lupus nephritis – one that didn’t include oral steroids. They looked at 50 people with SLE and lupus nephritis being treated in one hospital in London, who were not taking oral steroids. All 50 people were given a combination of three different
medicines, consisting of:

Two infusions of rituximab (a type of medicine called a monoclonal antibody), and just two infusions of a steroid called methyl prednisolone (instead of long-term oral steroids). These treatments were given directly into the vein through a drip, during hospital appointments at the beginning of the study and then two weeks later.
Twice-daily tablets of mycophenolate mofetil, a treatment that affects the immune system, which people took long-term.

The researchers then measured how much people’s symptoms improved after having treatment, and howmany had unwanted side effects or complications.

WHAT DOES THE NEW STUDY SAY?

During the study 45 of the 50 people had what the researchers called complete or partial remission of their kidney symptoms. Complete remission meant that the kidneys were working much better than they were before treatment started. Partial remission meant that the kidneys were working better than before treatment
started, but not as well as people in complete remission. The researchers followed up the people in the study for an average of 37 weeks, but some people took longer than this to achieve partial or complete remission.

Eleven people had relapses of their kidney symptoms and six had flare-ups of symptoms affecting other parts of the body.

HOW RELIABLE ARE THE FINDINGS?

This study looked at how one small group of patients who took a treatment did over time. But there’s a limit to how much we can draw from a small study of this kind. We need larger studies that show how it compares with other treatments.

WHAT DOES THIS MEAN FOR ME?

The researchers say that if larger, good-quality studies bear out these early results, it could lead to treatment that would avoid the side effects and complications common with oral steroids. But it is unlikely doctors will recommend this treatment until then.

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Date summary prepared: August 2013

Summary based on research article published on: 5 June 2013

From: Condon, M. et al. Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids. Ann Rheum Dis 2013;72:1280-1286 doi:10.1136/annrheumdis-2012-202844

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