Expert: Lupus Nephritis May be Treated with Lower Doses of Steroids

Liz Lightstone, PhD, FRCP, Professor of Renal Medicine, Imperial College London, joins Pharmacy Times to discuss the overlapping similarities, and differences, between the manifestation of lupus nephritis and vasculitis, how the pharmacist can assist patients with this disease, and other medications that can help patients.

Q: Do treatment therapies differ between diseases that manifest either as glomerulonephritis (GN) or vasculitis?

Liz Lightstone, PhD, FRCP:So, vasculitis and lupus are different. There are manifestations of lupus that are vasculitic, often in skin disease, but vasculitis is a disease that is very different.

I’ve got a few patients that switch between 1 or the other, but then I would treat according to vasculitis or according to their lupus. There are some overlaps in treatment, steroids are often used in both. Cyclophosphamide is used a lot in both, rituximab is used a lot in both, they were completely off-label in lupus. So, there are some similar mechanisms. It’s a vascular antibody driven disease. Drugs that target that part of the immune system will work and they will in lupus.

So, some overlap, but they really are very different diseases. They affect quite different populations; the vasculitis population is usually much older than the lupus population. So, there are similar drugs used, but they are much different disease entities and there are guidelines on how to treat one and how to treat the other.

Q: How can the community pharmacists raise more awareness about these new treatments?

Liz Lightstone, PhD, FRCP: That’s really difficult because, I suppose you get to know the patient to come in and are on their MMF, and they would not be seeing the patients on cyclophosphamide. The drugs are not widely in use yet- they are licensed, and I suspect in America they are used more than they are in the UK. But in the UK, they are certainly prescribed by experts, secondary tertiary care. I think the role of the community pharmacist would be more focused on encouraging adherence. You noticed someone wasn’t filling their prescriptions, I would go and start talking to them and seeing what the barriers were. I would find Out when I was talking to them, “Are you taking your tablets?” “What difficulties do you have? “

We have a particular problem in the UK because we must generically prescribe when there’s a generic. And what happens is the generic changes every time. It confuses patients. I think the community pharmacist has a big role in talking about adherence, about problems with the medication they’re taking, rather than necessarily promoting the new medication.

Q: Can other pharmaceutical drugs (not indicated for lupus nephritis) concurrently work with current treatments?

Liz Lightstone, PhD, FRCP: Oh yeah! So, what I think is really important is, we must not get… there’s the immune system, which we are attacking with our drugs, but then there’s everything else. And we know that if your blood pressure is badly controlled, your kidneys are going to do worse regardless. There’s really good evidence on that. We know that once you’ve had lupus nephritis, you are running with fewer nephrons (the functioning units of the kidney) so we need to protect those. These patients should all be on, almost certainly, an angiotensin blockade, so either an ACE inhibitor or a sartan, A lot of them are on low-dose aspirin, so pro-coagulant. And a lot of them get symptoms from their stomach, so they end up on a PPI. So, they end up with polypharmacy. So, encouraging and supporting them through that. And we should think about deprescribing when it is appropriate. Control the blood pressure, I would say, is the most important. And the other thing we think about is lipids, and especially if they are protein uric. They have high lipids, and they might well be on a statin.

Q: What would you like your fellow nephrologists to understand about Lupus nephritis?

Liz Lightstone, PhD, FRCP: I could go on about it for years. I would really like them to understand that we can treat it with much lower doses and steroids. The art is where we’re going to get them the best treatment and the most rapidly. So, we need an early renal biopsy. that you don’t miss the diagnosis, so you always stick the urine of your lupus patients. And if they start getting posturial, if they start getting active sediment, send them to somebody who is going to do a renal biopsy and treat them appropriately and rapidly to minimize their steroids. And even on high doses at the beginning, you can wean them down quite quickly.