Ten years later, in 1986, the group at the National Institutes of Health reported the long-term results of its trial with monthly pulses of cyclophosphamide and later on, in further trials, confirmed the beneficial effects of high-dose steroids by combining pulses of cyclophosphamide with steroid pulses.
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Explore This IssueFebruary 2017
It seems that, in the next decade, attempts to minimize steroid use in patients with systemic lupus erythematosus (SLE) and replacing it with B cell depletion are starting to grow, but even in that scenario, in the beginning, patients will still receive a limited number of pulse steroids. In a just-released paper, 69 SLE experts indicated their preferences to treat serious lupus nephritis, and high-dose steroids are still the first line of treatment, followed by mycophenolate.
In the next decade, it appears that biologics will be included in the standard of care. Currently, the only approved biologic drug for SLE is belimumab. Steroid pulse therapy is expected to continue to be used in periods of exacerbations.
The use of steroid pulse therapy since its publication has gained increased popularity in various clinical autoimmune disease states and is still an option for therapy after 40 years (see Table 1, below).
|Table 1: Pubmed Search 1976–2015|
|Lupus nephritis and pulse therapy||
|Lupus disease and pulse therapy||
|Autoimmune disease and pulse therapy||
Morton Scheinberg, MD, PhD, is an internist and rheumatologist at the Hospital Israelita Albert Einstein in São Paulo, Brazil, and director of clinical research at Hospital AACD, also in São Paulo. He received his PhD in immunology from Boston University, a Free Associate Professor from the Universidade São Paulo, and is an ACR Master.
- Kauntz SL, Cohn R. Initial treatment of renal allografts with large intrarenal doses of immunosuppressive drugs. Lancet. 1969 Feb 15;293(7590):338–340.
- Woods JE, Anderson CF, Deweerd JH, et al. High-dosage intravenously administered methylprednisolone in renal transplantation. A preliminary report. JAMA. 1973 Feb 19;223(8):896–899.
- Cathcart ES, Scheinberg MA, Idelson BA, Couser WG. Beneficial effects of methylprednisolone ‘pulse therapy in diffuse proliferative lupus nephritis. Lancet. 1976 Jan 24;307(7952):163–166.
- Austin HA 3rd, Klippel JH, Balow JE, et al. Therapy of lupus nephritis. Controlled trial of prednisone and cytotoxic drugs. N Engl J Med. 1986 Mar 6;314(10):614–619.
- Illei GG, Austin HA, Crane M, et al. Combination therapy with pulse cyclophosphamide plus pulse methylprednisolone improves long-term renal outcome without adding toxicity in patients with lupus nephritis. Ann Intern Med. 2001 Aug 21;135(4):248–257.
- Lightstone L. Minimising steroids in lupus nephritis—will B cell depletion pave the way? Lupus. 2013 Apr;22(4):390–399.
- Condon MB, Ashby D, Pepper RJ, et al. Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids. Ann Rheum Dis. 2013 Aug;72(8):1280–1286.
- Muangchan C, van Vollenhoven RF, Bernatsky SR, et al. Treatment algorithms in systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2015 Sep;67(9):1237–1245.
- Furie R, Petri M, Zamani O, et al. A phase III, randomized, placebo-controlled study of belimumab, a monoclonal antibody that inhibits B lymphocyte stimulator, in patients with systemic lupus erythematosus. Arthritis Rheum. 2011 Dec;63(12):3918–3930.
- Scheinberg M, de Melo FF, Bueno AN, et al. Belimumab for the treatment of corticosteroid-dependent systemic lupus erythematosus: From clinical trials to real-life experience after 1 year of use in 48 Brazilian patients. Clin Rheumatol. 2016 Jul;35(7):1719–1723.
- Scheinberg M. The history of pulse therapy in lupus nephritis (1976–2016). Lupus Sci Med. 2016 Apr 8;3(1):e000149.