'Choose wisely': Each biologic for lupus has 'ideal patient profile'
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DESTIN, Fla. — When choosing between biologic drugs for systemic lupus erythematosus, it is important to know the “ideal patient profile” each is best suited for, according to a speaker at the Congress of Clinical Rheumatology East.
Ronald van Vollenhoven, MD, PhD, of the Amsterdam University Medical Center, in the Netherlands, told attendees how they can “choose wisely” between belimumab (Benlysta, GlaxoSmithKline) and anifrolumab (Saphnelo, AstraZeneca), as well as rituximab (Rituxan, Genentech) and other off-label biologic agents, for patients with SLE.
In its 2023 recommendations for SLE treatment, EULAR states that biologic or immunosuppressive drugs should be considered for patients not responding to first-line treatment of hydroxychloroquine, with or without glucocorticoids. They add that initiation of anifrolumab or belimumab should not be dependent on prior use of a conventional immunosuppressive drug.
“This is a pretty strong recommendation,” van Vollenhoven said. “It means that you can step over conventional immunosuppressives. The insurers, they may disagree, but these recommendations are based on data.”
Anifrolumab and belimumab — as well as rituximab and other off-label drugs — should be used in cases of high disease activity, van Vollenhoven said. The choice narrows even further by considering other aspects of the patient profile.
Belimumab is ideally used in patients with anti-double stranded DNA antibodies and low complement levels, he added. Renal involvement also calls for belimumab — not “severe nephritis,” van Vollenhoven said, but rather patients with severe lupus pain in the skin, joints, lungs and heart, alongside “some activity in the kidneys.”
“The one thing that would probably argue against belimumab is if there is a serious concern about psychiatric side effects, which in some patients actually does make something to consider,” he said.
Anifrolumab, meanwhile, demonstrates “very good efficacy” for clearing up prominent skin involvement, according to van Vollenhoven. The drug is also glucocorticoid-sparing and effective at reducing flares.
“The patient at this point in time has to be OK with IV therapy every four weeks” he added. “The one concern that could be a bit of a limitation is if there’s a real concern that this patient is at risk for herpes zoster.”
Rituximab, though off-label for SLE, “becomes very reasonable to consider” in patients who have failed conventional immunosuppressives and approved biologics, according to van Vollenhoven. The drug should also be considered for patients with rheumatoid arthritis or vasculitis, he added.
“It becomes a whole different story, because those are two indications where rituximab is approved,” van Vollenhoven said.
Further off-label biologics can be considered in patients who have failed all the above, he concluded.
“When the patient has organ-threatening or even life-threatening disease, it’s the back against the wall,” he said. “We use everything we can.”
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Van Vollenhoven R. Update on SLE Treatment in 2024 — Getting Better All the Time. Presented at The Congress of Clinical Rheumatology East; May 9-12, 2024; Destin, Florida (hybrid meeting).
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