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Case in Point

Systemic Lupus Erythematosus in a 24-Year-Old

James Matera, MD

Volume 63 - Issue 7 - July 2023

  • Correct answer: B. Add belimumab to mycophenolate mofetil and utilize a corticosteroid-sparing regimen

    Discussion. Belimumab is a recombinant human monoclonal antibody that binds to soluble B-lymphocyte stimulator and inhibits its biological activity. It has become a very reasonable and effective option for treating lupus nephritis, particularly when the goal is to limit immune-modulating therapies, including corticosteroids. Some initial reports dating back to 2013 showed effectiveness, especially in refractory patients, including those treated with mycophenolate mofetil and cyclophosphamide.1

    Our patient would benefit from corticosteroid- and immune-sparing regimens, especially since she has experienced another flare. Prevention of these flares, which can be frequent during the patient's lifetime, is essential in limiting end-organ damage.2

    There have been 4 randomized controlled SOLE BLISS trials using belimumab. After 52 weeks of treatment with belimumab, the SLE Responder Index (SRI-4) improved by 54%, 68%, 83%, and 99% compared with standard therapy.3 In BLISS-LN, belimumab was added to standard therapy and compared with placebo, and patients were followed for 2 years.4 At the 104-week mark, more patients in the belimumab group had a primary efficacy renal response (43% vs 32%) and a complete renal response (30% vs. 20%).4

    Voclopsorin—a calcineurin inhibitor, has also been used in combination with standard therapy (mycophenolate mofetil and corticosteroids) and may become another agent for consideration for refractory lupus nephritis.5

    Patient outcome. Our patient has been on a regimen of mycophenolate mofetil (lower dose of 1000 mg twice daily), low-dose oral prednisone (5 mg every other day), and subcutaneous belimumab, 200 mg once weekly, which she administers herself. Her latest creatinine level was 0.8 mg/dL, and her 24-hr urine protein level decreased from 4300 mg/d 2 months ago to 634 mg/d now. She has minimal gastrointestinal adverse effects, which may be more related to concurrent mycophenolate mofetil therapy. As far as glycemic control, her last hemoglobin A1c level was 7.5% (a decrease from 8.8% 2 months ago), and daily continuous glucose monitoring is being utilized.

References

1. Fließer EE, Korsten P, Koziolek MJ, et al. Successful treatment of a mycophenolate mofetil-refractory proliferative lupus nephritis with belimumab in a 19-year-old woman. Lupus. 2013;22(14):1523-1525. doi:10.1177/0961203313504145

2. Adamichou C, Bertsias G. Flares in systemic lupus erythematosus: diagnosis, risk factors and preventive strategies. Mediterr J Rheumatol. 2017;28(1):4-12. doi:10.31138/mjr.28.1.4

3. Urowitz MB, Aranow C, Asukai Y, et al. Impact of belimumab on organ damage in systemic lupus erythematosus. Arthritis Care Res (Hoboken). Published online April 19, 2022. doi:10.1002/acr.24901

4. Furie R, Rovin BH, Houssiau F, et al. Two-year, randomized, controlled trial of belimumab in lupus nephritis. N Engl J Med. 2020;383(12):1117-1128. doi:10.1056/NEJMoa2001180

5. McArn AC, Nixon AR, Jarrell KL. Voclosporin: a novel calcineurin inhibitor for the treatment of lupus nephritis. Published online February 15, 2022. Ann Pharmacother. doi:10.1177/10600280221075331