The Takeaways
How should clinicians incorporate these therapies into their care?
Dr. Petri suggested they should consider a calcineurin inhibitor or belimumab with MMF right away if patients have a renal biopsy that is “very active.” Or clinicians could wait three months, or even six months, if they’d like to use a particularly conservative approach.
For patients who are particularly vulnerable in terms of safety factors or for whom GFR is a primary consideration, belimumab is likely the better option, she said. And for those with extra-renal lupus, it’s important to remember that this is where “belimumab shines,” she said.
If an immediate effect on proteinuria is the primary goal, voclosporin showed greater improvement at one year.
“What I’m asking you to do is change,” she said. “I’m going to change my own pattern of behavior and add belimumab or voclosporin earlier.”
Dr. Rovin suggested that with voclosporin’s rapid proteinuria effects and belimumab’s long-term protection of GFR, the two therapies might work well together. Aspects of both drugs “are really beneficial to the kidney.”
“What I’m looking for is, really, a way to take this to the next step,” he said.
“I have no objections, in a patient who isn’t responding, to adding both a calcineurin inhibitor and belimumab,” Dr. Petri said. “We don’t have any data on when to do that and how to do that and whether it should be sequential or additive. We need to collect these data. But again, given belimumab has such a great safety profile, I think it is an easy choice to add [it].”
Both doctors said identifying biomarkers to help guide treatment and simplify these choices should be the ultimate goal.
“I hope … what we’re going to see in the end are biomarkers that will help us decide which drug is appropriate for which patient,” Dr. Rovin said. “But maybe both drugs are appropriate for a lot of patients. And maybe they can be used together.”
Thomas Collins is a freelance medical writer based in Florida.
References
- Furie R, Rovin BH, Houssiau F, et al. Two-year, randomized, controlled trial of belimumab in lupus nephritis. N Engl J Med. 2020 Sep 17;383:1117–1128.
- Rovin BH, Teng YKO, Ginzler EM, et al. Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): A double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet 2021 May 29;397:2070–2080.
