Lupus

PRIMER
regimes were historically used and may still be required
in resistant disease, lower-dose regimes may be as
effective, even in renal SLE. These are likely to become
standard practice in future because they may reduce
glucocorticoid-associated comorbidities 132–134 . Patients
with lupus nephritis who are treated with lower-dose
glucocorticoids do not have worse symptoms than
patients given higher doses in a historical cohort 135 .
In another open-label study of 42 patients with SLE
with active proliferative lupus nephritis, a starting dose
of 0.5 mg per kg daily of prednisone was equally effective
as 1 mg per kg daily when combined with the immunosuppressive
mycophenolate mofetil 136 . Perhaps most
intriguingly, Condon et al. 137 suggested that initiation
treatment of proliferative lupus nephritis with rituximab
(a B cell-specific antibody) and only a single pulse of
intravenous glucocorticoid followed by mycophenolate
mofetil maintenance is highly effective. This protocol
is dubbed ‘rituxilup’ and is currently being tested in a
controlled trial.
The best-studied forms of lupus nephritis are
the more-severe types, classified according to the
International Society of Nephrology–Renal Pathological
Society modification of the WHO criteria as class III,
class IV and class V. These require more-aggressive
treatment to prevent progression to dialysis and early
mortality, which was a key issue with lupus nephritis
in the 1950s up until the 1970s. Historically, treatment
with a combination of glucocorticoids and intravenous
cyclophosphamide (a chemotoxic alkylating agent) was
preferred 138 . In 2002, the Euro-Lupus randomized trial
of 90 patients with SLE with proliferative glomerulonephritis
demonstrated that a reduced-dosage cyclophosphamide
regimen followed by azathioprine was as
effective as higher-dose intravenous cyclop hosphamide,
but was associated with considerably less tox icity 139 .
Later trials demonstrated that mycophenolate mofetil
was at least as effective for the treatment of lupus nephritis
as cyclophosphamide 138 . The 10‐year follow-up of
the Euro-Lupus low-dose cyclophosphamide cohort
demonstrated similar outcomes to the high-dose cyclophosphamide
group 140 . While glucocorticoid initiation
remains ‘best practice’, with the evidence to date, additional
initiation therapy with mycophenolate mofetil
is now an established option, with intravenous cyclophosphamide
or rituximab as alternatives. Maintenance
treatment with mycophenolate mofetil or azathioprine is
most commonly used thereafter.
Rituximab remains an enigma because several case
reports have suggested benefit in case series of resistant
lupus nephritis after standard treatment with a range of
immunosuppressants 141 . Despite this, the 52‐week randomized,
double-blind LUNAR clinical trial of rituximab
in 144 patients with SLE with class III or class IV
lupus nephritis showed no significant difference in the
primary end point of complete or partial renal response
defined by features including serum creatinine levels,
proteinuria and active urinary sediment 142 . There is
debate about whether the trial was underpowered and
whether trial design was compromised by the fact that
rituximab was an addition rather than a replacement
to conventional therapy including mycophenolate
mofetil 143 . The investigator-initiated, randomized RING
trial is currently addressing whether the addition of
rituximab to standard of care with azathioprine, mycophenolate
mofetil or intravenous cyclophosphamide
improves renal response rate after 104 weeks 144 .
Following the initial ‘induction’ phase of treatment
of lupus nephritis, maintenance therapy is usually given
for at least 2–3 years with azathioprine or mycophenolate
mofetil, the latter being slightly more efficacious with
fewer relapses 145,146 . Angiotensin-converting enzyme
inhibitors or angiotensin receptor antagonists are often
used as renoprotective agents. Additional therapeutic
options that can be considered are the use of intravenous
immunoglobulin, which probably works by
interfering with B cell, T cell and antibody function, or
plasma exchange, which aims to remove pathogenetic
antibodies from the circulation. These methods are useful
particularly when infection may preclude the use of
immunosuppressive agents 147 .
Quality of life
SLE can exert a profound effect on the life of patients,
both qualitative and quantitative, with higher mortality
rates than the general population. Compared with
healthy controls, patients with SLE report lower levels of
vitality and general health, with a marked effect of SLE
on physical functioning, psychological and emotional
status and social life 148 . The physical and mental components
of the 36‐Item Short-Form Health Survey (SF‐36)
— a general QOL indicator — have been consistently
reduced in patients with SLE compared with controls.
A large number of patients with SLE report tiredness,
pain, exacerbation, anxiety about the condition and
exacerbations, inability to carry out daily tasks and fear
of physical disability 148 . A study in California showed
a progressive decline in the proportion of patients
with SLE who were employed between 2002 and 2004
(REF. 149). While 74% of patients with SLE were working
at the time of diagnosis, only 55% were employed
at the time of the survey, an average of 12 years later.
A progressive decline in working hours among those
employed was seen: 1,105,401 total hours worked among
those employed in the year of their diagnosis, 746,982
hours at the baseline interview and 654,480 hours a
year later. Although there was no control group in the
study, all respondants were <65 years of age at the time
of the survey. In addition, in Europe, a negative effect
on produc tivity and professional development has been
found using a survey of 2,070 patients with SLE 150 .
Several scales have been used to measure
the health-related QOL of patients with SLE. Besides the
generic SF‐36 questionnaire, SLE-specific instruments
have been proposed: the Lupus QOL (LupusQOL),
the Systemic Lupus Erythematosus-Specific QOL
Questionnaire (SLEQOL) and the Systemic Lupus
Erythematosus QOL Questionnaire (L‐QOL). These
instruments have been recently reviewed 151 .
Whichever scale is used, some SLE-related issues
consistently correlate with a decline in QOL of the
patient (TABLE 4). Both SLE activity and irreversible organ
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