Fifty years ago, the only immunosuppressants available for lupus were cyclophosphamide and azathioprine. Since then, mycophenolate has been developed as well. There’s only one biologic geared toward lupus—belimumab—but Dr. Schur finds its efficacy mediocre, at best. “This is in contrast to dramatic changes in RA. There have been many biologic trials [in lupus], but they’ve mostly failed,” he says. The clinical trials may not have insightful results, because all patients with lupus are lumped together, rather than separating them by which organs are affected and how active the disease is, Dr. Schur says.
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Explore This IssueJune 2017
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Tailoring the use of treatment protocols is often determined today by the clinical stratification of disease, Dr. Schur says. In fact, some patients may not need treatment initially. “We now recognize that some patients have such mild disease that it needs no treatment or intermittent illness that is best responded to by treatment guided by careful consideration of the long-term consequences of therapy, such as steroid-induced osteoporosis or osteonecrosis,” he says.
Research through time has also shed light on how race may affect how patients respond—or don’t respond—to medications. This includes the finding of African American patients not responding as well to treatments with mycophenolate. These types of findings will continue to affect medical management in the future, Dr. Schur says.
Medical research also continues to reveal immune-based targets for therapy, including innate immune mechanisms, adaptive immunity, effector cells, effector pathways, soluble inflammatory mediators and signaling molecules, Dr. Schur explained.
More Effective Management of Concurrent Conditions
Another area that has helped boost the survival rate for lupus patients is better treatment for concurrent skin, renal and joint conditions commonly associated with lupus, Dr. Schur says. Fifty years ago, there was only a crude version of sunscreen available, unlike the sophisticated and potent formulations available now. Better use of sunscreen has helped protect patients from related skin conditions. Lupus patients now also commonly use hydroxychloroquine (Plaquenil), which has reduced the incidence and severity of skin disease. Dermatologists also have become more sophisticated with their classification and treatments for patients with lupus and skin conditions.
Decades ago, clinicians thought patients with lupus could not get kidney transplants if renal disease struck them. “It was thought that they wouldn’t do well, but they do as well as anybody else. … I have a patient with a kidney transplant from more than 30 years ago who continues to do well, with normal renal function. That’s been dramatic,” Dr. Schur says.