“I think the most impressive part of belimumab is that it decreases the risk of severe flares when added to hydroxychloroquine,” he continued. “It also increases the probability of remission, but both take some time.”5
Dr. Aringer also expressed enthusiasm for anifrolumab, which may be a faster acting drug than belimumab. “We start to see a difference starting at four to eight weeks. We see the biggest impact on the mucocutaneous and musculoskeletal manifestations, and glucocorticoid dose reduction,” he said.6,7 Anifrolumab is also under investigation for the treatment of lupus nephritis, with phase 3 trials underway.8
In terms of safety, Dr. Aringer noted, “There’s a statistically significant difference in herpes zoster infections, and a bit of a numerical signal for influenza. That makes sense since nature made interferon for fighting viral infections.”9
Dr. Aringer mentioned voclosporin only briefly, as it’s not yet widely available in Europe. He noted, however, that it has a “great and probably direct effect on proteinuria.”10
Although never FDA approved, rituximab still has a role for certain people with SLE (e.g., cytopenias, neuropsychiatric SLE, lupus nephritis). “The randomized, controlled trials were negative, but there were real issues regarding trial duration, amount of glucocorticoids, etc. There are numerous large cohort publications in which we saw a lot of improvement across the field,” he noted.11,12 Rituximab is out-of-patent, thus new trials in SLE are unlikely. However, new anti-CD20 therapies, like obinutuzumab, are under further study in lupus nephritis.13
Medication regimens for SLE patients can be as heterogenous as the patients themselves.
Baricitinib drug development in SLE was halted in January 2022 after two phase 3 studies failed to show adequate benefit.14 However, case reports have noted impressive results for mucocutaneous manifestations of SLE.15 “We’ll learn more about the potential efficacy of Janus kinase inhibitors in SLE in the next few years. More trials are ongoing,” Dr. Aringer said.
Though most rheumatologists avoid tumor necrosis factor-alpha (TNF-α) inhibitors in SLE due to the association with drug-induced SLE, Dr. Aringer reminded us that an observational study demonstrated the safety and efficacy of etanercept for lupus arthritis.16 He said, “In really severe and untreatable lupus arthritis, one should be aware of this option.” These data are specific to etanercept, but not other TNF-α inhibitors.
Tocilizumab may also be an option for severe lupus arthritis.17 “Both the tocilizumab and etanercept trials were uncontrolled studies, but something to keep in your back pocket,” he remarked.
