- In people with any LN class with an inadequate renal response (i.e., have not achieved at least a partial renal response by 6–12 months) we conditionally recommend escalation of treatment:
- For initial dual therapy, escalate to triple therapy.
- For initial triple therapy, change to an alternative triple therapy or consider addition of an anti-CD20 agent as a second immunosuppressive.
- In people with any LN class with refractory disease (i.e., failed two standard therapy courses), we conditionally recommend treatment escalation to a more intensive regimen, including addition of anti-CD20 agents, or combination therapy with three non-glucocorticoid immunosuppressives (i.e., MPAA, belimumab and CNI), or referral for investigational therapy.
Definitions & Abbreviations
Triple therapy: GC [pulse intravenous glucocorticoids (250–1,000 mg methylprednisolone daily x 1-3 days) followed by oral glucocorticoid (≤0.5 mg/kg/day, maximum dose 40 mg/day) with taper] plus 2 additional immunosuppressive therapies, usually a) MPAA plus belimumab or b) MPAA plus CNI or c) ELNT low-dose CYC plus belimumab (MPAA substituted for CYC after CYC course complete).
Dual therapy: GC [pulse intravenous glucocorticoids (250–1,000 mg methylprednisolone daily x 1–3 days) followed by oral glucocorticoid (≤0.5 mg/kg/day, maximum dose 40 mg/day) with taper] plus one additional immunosuppressive therapy, usually MPAA or ELNT low-dose CYC.
Anti-CD20 therapy: rituximab or obinutuzumab; AZA: azathioprine; BEL: belimumab; CNI: calcineurin inhibitor therapies (cyclosporine, tacrolimus, voclosporin); CYC: cyclophosphamide; ELNT: EuroLupus Nephritis Trial; ESKD: end stage kidney disease; GC: glucocorticoids; HCQ: hydroxychloroquine; MPAA: mycophenolic acid analogs (including mycophenolate mofetil, MMF, and mycophenolic acid, MPA); RAAS-I: renin-angiotensin-aldosterone system inhibitors (including angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists).
Abstracted from the Guideline Summary:
