Early Adoption of Advanced Systemic Therapies in Lupus Nephritis: A Retrospective Analysis

Background: Recently, KDIGO and EULAR have issued updated guidelines concerning the management of SLE and LN. These updates advocate for the early use of belimumab and CNIs in the treatment of active LN. Our study delves into US rheumatologists' and nephrologists' strategies for using advanced systemic therapies in LN. Methods: 1,043 ISN Class III or IV (+/-V) and Class V adult LN patient records were collected in collaboration with 107 US rheumatologists and 90 US nephrologists via an online survey from September to November 2023. These patients had to be in the maintenance phase of treatment and have an eGFR greater than 15 mL/min/1.73m2. This retrospective analysis focuses on the subset of 669 LN patients diagnosed in 2021 or later. Results: Nearly half (48%) of patients were on an advanced systemic agent during their latest specialist visit, with belimumab being the most commonly prescribed (32%), followed by voclosporin at 12% and rituximab at 4%. Notably, 61% of patients were on oral steroids. About one-third of patients treated with advanced systemic agents for LN received such treatment either before or at the time of diagnosis. Moreover, the majority of patients initiated advanced systemic therapy within six months of diagnosis. There was no discernible difference in the timing of initiation between belimumab, voclosporin, and rituximab by specialists. Upon initiation of belimumab or voclosporin, patients were prescribed an average of 20mg of oral steroids daily. A notable distinction between patient groups was observed in proteinuria levels, with those receiving voclosporin exhibiting higher levels compared to belimumab. Conclusion: These results underscore a growing emphasis on initiating systemic treatments earlier in the treatment trajectory, yet high doses of steroids remain prevalent. Despite the earlier adoption of advanced systemic therapies, there persists an unmet need for steroid-sparing agents to mitigate the continued reliance on high-dose steroids.