Effect of Cyclosporine- vs. Voclosporin-Based Regimen in a Patient with Class V Lupus Nephritis

Introduction: Background: Cyclosporine and Voclosporin are both calcineurin inhibitors (CNI) that have been used to treat lupus nephritis. However, there has never been a head-to-head study comparing these two medications. We present a case of a class V LN patient who had a partial response to cyclosporine and complete response after switching to voclosporin. Case Description: 30 yo female presented with nephrotic syndrome in 2021. Serology shown +ANA, +SSA, +Smith, +RNP and clinical symptoms of fatigue, alopecia,and rashes including a malar rash and inflammatory oligoarticular arthralgias. She was started on Plaquenil (hydroxychloroquine) 300 mg daily. Biopsy showed membranous lupus nephritis with zero activity index and zero chronicity index. She was initially treated with Benlysta (Belimumab) with no response. In Feb 2023, she was started on multiple-targeted therapy with prednisone, mycophenolate mofetil and cyclosporine. Cyclosporine was chosen over tacrolimus due to concerns of diabetogenic side effect of tacrolimus. She had a partial response with a drop in the urine protein to creatinine ratio (UPCR), from 6 mg/mg to 2 mg/mg. In Oct 2023, cyclosporine was switched to voclosporin. Her UPCR ratio dropped to zero with voclosporin signaling a complete response. In addition, her serum LDL normalized after switching to voclosporin (Table). Discussion: Although both are CNI, voclosporin seems to have better efficacy in this patient with class V LN and less hyperlipidemia side effects. Further studies are needed to distinguish if this is an isolated phenomenon or not. Cyclosporine vs Voclosporin in Class V Lupus Nephritis - Benlysta Cyclosporine Regimen Voclosporin Regimen UPCR 6.2 2.4 0.06 Serum Albumin (g/dl) 2.2 3.0 4.4 LDL (mg/dl) 95 320 79 Creatinine (mg/dl) 0.6 0.7 0.7 eGFR (ml/min/1.73m2) >60 >60 >60