SHANGHAI, China—Mycophenolate mofetil may replace cyclophosphamide as the preferred treatment in lupus nephritis, even without regulatory approval in many countries, according to Tak Mao Chan, MD, professor of medicine at the University of Hong Kong's Queen Mary Hospital, in China, who discussed current approaches to lupus nephritis at the 8th International Congress on SLE.¹

"The favorable efficacy and tolerability profile, and the ease of treatment without hospitalization or intravenous drug administration, has resulted in [mycophenolate mofetil and corticosteroid] being increasingly adopted as standard therapy, often before formal regulatory approval," Dr. Chan said.

The move to this new regimen is grounded in the well-recognized adverse effects associated with cyclophosphamide (which Dr. Chan said can be reduced, but not totally averted, by limiting dose and/or duration of treatment) and by the lower efficacy of an azathioprine-based regimen.

"Recent reports from the Dutch Working Party on SLE showed inferior renal function after around 6 years of follow-up and worse follow-up renal histology in patients with severe proliferative lupus nephritis treated with an azathioprine-methylprednisolone regimen, compared with pulse cyclophosphamide and oral prednisone, and the difference was attributed to more frequent relapse and subclinical immune-mediated inflammation in the azathioprine group," Dr. Chan pointed out.

Dr. Chan reviewed data showing response rates in excess of 90% in Chinese patients with severe proliferative lupus nephritis who received mycophenolate mofetil plus prednisolone; data from studies in the US show response rates of 50% in African-American and/or Hispanic patients who received the same treatment regimen. "Favorable results with mycophenolate mofetil and corticosteroid as first-line therapy have also been obtained in other Asian countries and in cohort studies in Europe," he noted.

Dr. Chan also noted that calcineurine inhibitors "have a role in the treatment of membranous lupus nephritis, but in view of their nephrotoxicity should be used judiciously and reserved for patients with heavy proteinuria." He advised that inhibition or blockade of the renin-angiotensin system can improve proteinuria caused by glomerular sclerosis.

"Immunosuppression is but one facet in the management of patients with lupus nephritis," Dr. Chan concluded. "Among the comorbidities and potential long-term complications, the importance of preventing cardiovascular events cannot be overemphasized."

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Reference

1. Chan TM. Treatment of lupus nephritis in 2007. Presented at: 8th International Congress on SLE; May 24, 2007; Shanghai, China.