Assoc. Dr. İsmail Şimşek
The development of nephritis (kidney inflammation) in a patient with lupus is considered to be one of the most serious complications of the disease, and despite all the developments in the treatment of lupus in the past years, a significant reduction in the frequency of the disease progressing and undergoing dialysis could not be achieved after kidney involvement. The treatment of lupus kidney involvement is planned by doctors in 2 stages. The first of these stages is the suppression of the exacerbation of the disease called induction, and the second is the longer-term treatments, called the maintenance period, to prevent the re-exacerbation of the disease, which was suppressed in the first stage.
It has long been debated among rheumatologists whether the slightly more expensive mycophenolate for maintenance therapy has an advantage over the less expensive immunosuppressive azathioprine. The results of the ALMS (Aspreva Lupus Management Study), which seeks to answer how the treatment should be in lupus nephritis, were published in the November 17 issue of The New England Journal of Medicine.
227 lupus patients with class III, IV, and V lupus kidney involvement and whose disease was suppressed by induction therapy (using cyclophosphamide or mycophenolate) participated in the study. Some of the patients were given 2 grams of mycophenolate mofetil per day, and some of them were given 2mg/kg/day azathioprine and were followed for 3 years.
In the study, it was basically investigated which maintenance treatment would cause less exacerbation of the disease. At the end of the 3rd year, disease exacerbation was observed at a rate of 16% in the mycophenolate group, while this rate was found to be 32% (2 times more) in the azathioprine group. In addition, it was observed that the superiority of mycophenolate over azathioprine was not affected by the drug (cyclophosphamide, mycophenolate, etc.) of the induction therapy that the patient received. In the study, many other parameters related to the disease were evaluated and mycophenolate was found to be superior to azathioprine in almost all of them.
In conclusion, according to the results of this study, using mycophenolate seems to be more advantageous than azathioprine in the maintenance of lupus kidney involvement. On the other hand, although the 3-year follow-up period seems long, the experience we have gained from previous lupus studies is that it is necessary to follow up for 5-20 years in order to have an idea about the real effects of drugs in these patients.
Which drug should be used in the maintenance treatment of lupus nephritis? Mycophenolate (cellcept) / azathioprine (imuran)
