Lupus nephritis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omer Kamal, M.D.[2]

The mainstay of therapy for systemic lupus erythematosus (SLE) is to control disease activity and prevent organ damage. The treatment of choice for systemic lupus erythematosus (SLE) varies based on the severity of the disease and symptoms. Generally, all the patients with any type of SLE manifestation should be treated with hydroxychloroquine regardless of the level of their disease. Other pharmacologic medical therapies for SLE include glucocorticoids like oral prednisone or intravenous methylprednisolone, NSAIDs like celecoxib, and immunosuppressive therapy with mycophenolate, cyclophosphamide, or rituximab, particularly in severe cases. Cutaneous lupus erythematosus (CLE), if presented separately without any other system involvement, can be treated with topical corticosteroids. Other organ-related complications of SLE should be treated separately.

Treatment goals in systemic lupus erythematosus (SLE) include:

• Ensure long-term survival
• Achieve the lowest possible disease activity
• Prevent organ damage
• Minimize drug toxicity
• Improve quality of life

• Hydroxychloroquine: 200 to 400 mg daily as a single daily dose or in 2 divided doses.
  • Generally, all patients with any type of SLE manifestation should be treated with hydroxychloroquine regardless of the severity of the disease.

The treatment choice for systemic lupus erythematosus (SLE) is varied based on the severity of the disease and symptoms:

• Mild cases are defined as disease pattern with one or two organ involvement.
• Moderate cases are defined as more than 2 organ involvement during disease flares with low grade of involvement and complications or one or two organ involvement with more extensive involvements.
• Severe cases are defined as presentation of the disease with life threatening complications and multiple (more than 2) organ involvements.

• Aggressive antihypertensive therapy with blood pressure goal of 130/85
• In patients with proteinuria, antiproteinuric therapy with blockade of the renin-angiotensin system include ACEIs and ARBs:
  • ACE inhibitors; captopril PO 25 mg 3 times daily
    • Antiproteinuric effect 
  • ARBs; losartan PO initial: 50 mg once daily; can be increased to 100 mg once daily based on blood pressure response
    • Slowing progression of GFR decline;
• Lipid lowering with statin therapy with the goal of LDL< 130

• Diffuse or focal proliferative LN:
  • Preferred regimen: Immunosuppressive therapy with glucocorticoids plus either intravenous or oral mycophenolate mofetil: 0.5 g of mycophenolate mofetil twice daily for the first week, then 1 g twice daily for the second week, and thereafter increase the dose to 1.5 g twice daily
  • Alternative regimen: Immunosuppressive therapy with glucocorticoids plus IV cyclophosphamide 500 mg every two weeks for a total of six doses

• Severe active disease: 
  • Preferred regimen: Glucocorticoid therapy is initiated with intravenous pulse methylprednisolone (250 mg to 1000 mg given over 30 minutes daily for three days) to induce a rapid immunosuppressive effect, followed by conventional doses  
  • Alternative regimen: Conventional doses of oral glucocorticoids (eg, 0.5 to 1 mg/kg per day of prednisone) without a pulse.
    • Oral prednisolone at a dose of 60 mg/day, tapered every two weeks by 10 mg/day until 40 mg/day is reached, then tapered by 5 mg/day until 10 mg/day is reached 

• Appropriate adjunct therapy:
  • Vitamin D and calcium supplements for preventing osteoporosis in patients using corticosteroids
  • Antihypertensive drugs and statins were also recommended in patients using corticosteroids
• Adverse effects: Cutaneous atrophy is a potential side effect of the long-term use of topical steroids

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