DR Medhat MRCP

Immune suppression in MN :
1 ST line (Ponticelli regimen): Alternating monthly steroids and alkylating agents X 6 m
- Month 1: IV methylprednisolone 1g x 3, then oral methylprednisolone
(0.5mg/kg/day) for the remainder of the month.
- Month 2: oral cyclophosphamide 2.0mg/kg/day
(or chlorambucil 0.15 – 0.2mg/kg/day).
- Month 3: repeat month 1.
- Month 4: repeat month 2.
- Month 5: repeat month 1.
- Month 6: repeat month 2.
For practical reasons, many clinicians adapt this to a non-cyclical regimen i.e
- Prednisolone 1mg/kg/day PO daily (max 60 mg) (with or without pulse IV)+
- Cyclophosphamide 1.5 – 2.0mg/kg/day PO, tapering steroids against
response.
Whilst this is common practice, it does not have the evidence base available for
the cyclical regimen.
2 nd line alternative to alkylating agents calcinurin inhibitors :
o Indications : Alternative when alkylating agents are undesirable e.g
- Female in child-bearing age (high risk of infertility).
o Give either :
- Ciclosporin 3.5 – 5mg/kg/day in two divided doses, with low
prednisolone (0.15mg/kg/day) for at least 6 months. OR
- Tacrolimus 0.05– 0.075mg/kg/day in two divided doses (alternative)
o How to give Calcinurin inhibitors :
Start at lower dose, and titrate up, as tolerated.
Watch GFR closely.
CNI levels should be monitored, particularly during the initial stages.
If no response, stop at 6 months.
In those that respond, aim to reduce to the minimum dose that maintains
remission, and continue for at least 12 months.
MMF + Steroids low evidence –based , high risk of relapse.
Rituximab (375mg/m 2 weekly x 4 doses) : lack of long-term follow up results.
TTT of relapse : same regimen that was successful initially (alk.agents are used
only once more).
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