New therapies for difficult to treat lupus
By Dr. Robert Katz, Chair Lupus Society of Illinois Board of Directors and Medical Advisory Board
One of the goals of management is to treat active lupus symptoms and inflammation but keep steroid dose down.
For mild to moderate lupus, methotrexate and azathioprine are options, and for more significant disease, mycophenolate and the newer therapies are avaiable including belimumab (Benlysta), anifrolumab (Saphnelo), and voclosporin (Lupkynis). In quite severe lupus, cyclophosphamide and rituximab should be considered along with prednisone. Prednisone can be used in mild, moderate, or severe disease, but the side effects of steroids, depending on the dose, include weight gain, facial and body puffiness, increased anxiety at times, bone loss, effect on blood sugar and other side effects with long-term therapy. Hydroxychloroquine (Plaquenil) is a commonly given medicine for milder lupus.
Some of the therapies like mycophenolate and azathioprine take a while to work, and the peak effect may not be seen for many months. Anifrolumab (Saphnelo) has an impact on joint pain and rashes and allows steroid reduction. It is under investigation for the treatment of lupus kidney disease. Voclosporin (Lupkynis) has a significant effect on proteinuria or excessive protein excretion in patients with lupus kidney disease.
Rituximab (Rituxan), given intravenously, has never been approved for lupus, but has an important role for certain problems including lupus kidney disease, neuropsychiatric lupus, and blood count abnormalities. There may be a lot of improvement and a reduction in steroid therapy on rituximab. There are other similar therapies that are under study for lupus kidney disease including one called obinutuzumab. (“Mab” means monoclonal antibody) Although baricitinib (Olumiant) had a research trial halted before the drug was able to be approved, it does seem to have a significant effect on the rash of lupus patients, and other similar drugs called kinase inhibitors are being experimented with in lupus.
There are several case reports about the use of TNF blockers like Enbrel for hard to treat lupus arthritis and other studies on tocilizumab (Actemra) for severe lupus arthritis. These are not based on well controlled studies but are options for some lupus patients.
It is important for the patient to realize that therapies may take months to work, but there are more and more options for treatment that are available and allow control of the disease when it flares without using long-term, high-dose prednisone.