ACR recommends triple therapy for lupus nephritis in new 2024 guidelines
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WASHINGTON — Early triple therapy may be the most effective strategy for lupus nephritis, according to the new 2024 American College of Rheumatology Guideline for the Screening, Treatment, and Management of Lupus Nephritis.
The 2024 document, which was presented in a press conference at ACR Convergence 2024, includes 41 recommendations overall.
“We have very convincing evidence that starting with triple therapy yields better long-term outcomes for our patients than starting with two agents and waiting to see if they respond before escalating to triple therapy,” Lisa Sammaritano, MD, lead author of the updated guideline, professor of clinical medicine at Weill Cornell Medicine, and an attending physician in the Hospital for Special Surgery, said at the press conference.
According to Sammaritano, the ACR’s previous lupus nephritis clinical practice guidelines had called for induction therapy, with high-dose glucocorticoids plus immunosuppressant medications, such as mycophenolate mofetil or cyclophosphamide, as well as mycophenolate for maintenance therapy.
“Since then, belimumab and voclosporin have been approved by the FDA for treatment, prompting a conceptual shift from induction and maintenance therapy to one of combination, ongoing therapy targeting different parts of the immune system,” Sammaritano said in a press release announcing the update.
Among the new document’s strong recommendations, the ACR counsels rheumatologists to screen for proteinuria at least every 6 to 12 months — or in the event of extra-renal flares — in patients with systemic lupus erythematosus who do not have known kidney disease. Quantifying proteinuria at least every 3 months in patients with lupus nephritis who have not reached a complete renal response is also strongly recommended. For patients with sustained complete renal response, proteinuria screening should occur every 3 to 6 months.
Meanwhile, a key conditional recommendation for screening suggests rheumatologists perform a kidney biopsy in patients with SLE demonstrate high protein levels in their urine — defined as 0.5 g/g — and/or impaired kidney function not otherwise explained.
Regarding treatment, an immunosuppressive triple-therapy regimen is conditionally recommended in patients with active Class III & IV lupus nephritis. This regimen may include glucocorticoid plus mycophenolate plus belimumab (Benlysta, GlaxoSmithKline), mycophenolate plus calcineurin inhibitor therapy, or low dose cyclophosphamide plus belimumab.
Lower doses of glucocorticoids are recommended after initial IV pulse therapy, according to the document.
In addition to recommendations for adults and pediatric patients, the guideline also includes recommendations for withdrawing therapy, according to Sammaritano.
“We are also recommending 3 to 5 years of treatment,” she said. “We know that while clinical response may occur, often times there is still ongoing inflammation in the kidney itself. We want to make sure that is completely treated before withdrawing medication.”
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Sammaritano L. Press conference. Presented at: ACR Convergence 2024; Nov. 14-19, 2024; Washington, D.C.
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